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  • 1.
    Arnberg, Filip K.
    et al.
    Uppsala University, Sweden .
    Linton, Steven J.
    University of Örebro, Sweden .
    Hultcrantz, Monica
    Swedish Council Health Technology Assessment, Sweden.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Jonsson, Ulf
    Swedish Council Health Technology Assessment, Sweden Karolinska Institute, Sweden .
    Internet-Delivered Psychological Treatments for Mood and Anxiety Disorders: A Systematic Review of Their Efficacy, Safety, and Cost-Effectiveness2014In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 9, no 5, p. e98118-Article in journal (Refereed)
    Abstract [en]

    Background: Greater access to evidence-based psychological treatments is needed. This review aimed to evaluate whether internet-delivered psychological treatments for mood and anxiety disorders are efficacious, noninferior to established treatments, safe, and cost-effective for children, adolescents and adults. Methods: We searched the literature for studies published until March 2013. Randomized controlled trials (RCTs) were considered for the assessment of short-term efficacy and safety and were pooled in meta-analyses. Other designs were also considered for long-term effect and cost-effectiveness. Comparisons against established treatments were evaluated for noninferiority. Two reviewers independently assessed the relevant studies for risk of bias. The quality of the evidence was graded using an international grading system. Results: A total of 52 relevant RCTs were identified whereof 12 were excluded due to high risk of bias. Five cost-effectiveness studies were identified and three were excluded due to high risk of bias. The included trials mainly evaluated internet-delivered cognitive behavioral therapy (I-CBT) against a waiting list in adult volunteers and 88% were conducted in Sweden or Australia. One trial involved children. For adults, the quality of evidence was graded as moderate for the short-term efficacy of I-CBT vs. waiting list for mild/moderate depression (d = 0.83; 95% CI 0.59, 1.07) and social phobia (d = 0.85; 95% CI 0.66, 1.05), and moderate for no efficacy of internet-delivered attention bias modification vs. sham treatment for social phobia (d = 20.04; 95% CI 20.24, 0.35). The quality of evidence was graded as low/very low for other disorders, interventions, children/adolescents, noninferiority, adverse events, and cost-effectiveness. Conclusions: I-CBT is a viable treatment option for adults with depression and some anxiety disorders who request this treatment modality. Important questions remain before broad implementation can be supported. Future research would benefit from prioritizing adapting treatments to children/adolescents and using noninferiority designs with established forms of treatment.

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  • 2.
    Brodtkorb, Thor-Henrik
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Förutsättningar för etablering av en nationell prioriteringskommitté i hälso- och sjukvården: Erfarenheter från andra länder2011Report (Other academic)
    Abstract [sv]

    Syftet med denna studie är att redovisa förutsättningar för en nationell kommitté eller motsvarande för utvärdering och prioritering vid beslut avseende införande av andra sjukvårdsteknologier än läkemedel i hälso- och sjukvården samt att presentera för- och nackdelar med olika lösningar.

    Huvuddelen av underlaget till studien kommer från intervjuer med ett flertal internationella aktörer - för att fånga ett brett faktaunderlag om hur andra länder har agerat i frågan. De länder som har ingått i studien är Australien, England, Kanada, Nederländerna, Norge, Nya Zeeland och Spanien. Utöver intervjuer med nyckelpersoner i respektive land har vi genomfört två workshops med representanter från Nationella samordningsgruppen för kunskapsstyrning. Statliga myndigheter och företrädare för medicintekniska företag har varit inbjudna att delta.

    Vi bedömer att det är realistiskt och motiverat att överväga införande av ett nationellt system för utvärdering och beslut om införande och utmönstring av icke-farmakologiska sjukvårdsteknologier. I ett sådant system förutsätts att beslut fattas av någon typ av nationell prioriteringskommitté eller nämnd, fortsättningsvis i rapporten förkortad NPK.

    Vårt uppdrag har varit att presentera och diskutera olika praktiska och principiella komponenter i ett sådant system. Hur organisationen bör utformas i detalj har vi inte tagit ställning till då frågan ligger utanför vårt uppdrag. I genomgången har vi pekat på fördelar och nackdelar med olika lösningar för de tio komponenter som vi menar utgör byggstenarna för en NPK. Baserat på dessa för- och nackdelar, men utan att ta ställning till organisatoriska eller tidsmässiga aspekter, eller omfattningen på verksamheten, så framträder för oss ett huvudalternativ. Detta huvudalternativ bör diskuteras i relation till alternativa lösningar och preciseras ytterligare.

    Med tanke på att utgångspunkten för denna rapport har varit att undersöka förutsättningar för etablering av en nationell prioriteringskommitté i hälso- och sjukvården, är det också naturligt att vi haft den nationella nivån som utgångspunkt. Varje land vi har undersökt har ett system som är utformat för att passa in i den sjukvårdsstruktur och finansiering som finns i det enskilda landet. Då ansvaret för Sveriges hälso- och sjukvård delas mellan stat och landsting, förefaller det mest adekvat att staten får ansvar för samordning, tillhandahållande av beslutsstöd och kompetens (via myndigheter och kommittéer) och att en NPK formas och drivs av staten tillsammans med sjukvårdshuvudmännen. De sistnämnda har ansvar för att producera och finansiera hälso- och sjukvården. En sådan organisation vore mest i linje med dagens sjukvårdssystem och hur finansieringsansvaret är uppdelat. Alternativet är att bilda ett nationellt organ med enbart företrädare från regioner och landsting. Mot detta talar att statens expertkompetens utnyttjas i lägre grad och att det finns en risk att regionalpolitiska hänsynstaganden kan spela en alltför stor roll.

    Med tanke på att budgetansvaret för att bekosta nya teknologier i hälso- och sjukvården i Sverige i huvudsak ligger på landstingen så förfaller det ologiskt att förorda direkt budgetansvar för NPK. Därmed inte sagt att kostnadsmedvetenhet inte är mycket viktigt i en sådan kommitté. Det bör därför vara en kommitté som kan balansera budgethänsyn med kostnadseffektivitet och rättvis fördelning av resurser.

    De flesta länder strävar mot ett system som är inkluderande när det gäller vilka typer av teknologier som ska ingå i utvärderingarna. De flesta typer av teknologier, både gamla och nya, ter sig därför som aktuella även i Sverige. Samtidigt är det tydligt att det inte går att utvärdera alla teknologier med tanke på den stora arbetsmängd detta skulle leda till. Den svenska branschorganisationen Swedish Medtech uppskattar att det idag finns cirka en halv miljon unika medicintekniska produkter och utifrån detta så förstår vi att inflödet av enbart nya medicintekniska produkter är mycket stort. Dessutom innebär många av dessa endast marginella förändringar jämfört med tidigare teknologier. Vi förespråkar ett system som prioriterar vilka teknologier som ska utvärderas baserat på deras konsekvenser (hälsoeffekt, ekonomisk omfattning, etisk kontrovers etc.) snarare än typ av teknologi eller om den är gammal eller ny. På detta sätt undviks att vissa typer av teknologier får ”fribrev” in isystemet.

    Det finns tre huvudalternativ med tanke på vem som tar fram kunskapsunderlag till utvärderingarna: 1. Enbart företagen; 2. Enbart den beslutande kommittén eller motsvarande; 3. Dessa två kombinerat. Baserat på våra erfarenheter från andra länder och även de återkopplingar vi har fått från referensgruppen tror vi att det vore olyckligt att införa ett system som helt utesluter företagen som uppgiftslämnare. Framför allt kommer NPK i sådana fall att gå miste om dataunderlag som ännu inte är publicerat men som kan vara av stor vikt för besluten. Dock behöver företagsbaserade underlag givetvis granskas av någon oberoende instans innan beslutet fattas.

    Det finns behov av tydliga incitament för att lyfta frågor till utvärdering och beslut. Erfarenheter från Västra Götalandsregionen tyder på att den startfinansieringsmodell som tillämpas där har varit ett lyckat sätt för att få in förslag på teknologier som bör utvärderas. Incitament behöver dock inte alltid vara av ekonomisk art utan kan även vara av administrativ karaktär. Registrering av alla nya teknologier (produkter och procedurer) i ett register innan de får användas skulle kunna bidra till att identifiera kandidater för utvärdering.

    Samtliga länder vi har undersökt har valt att ha flera aktörer involverade i processerna för identifiering, utvärdering, prioritering och beslut angående införande. Flera informanter har även framhållit vikten av att separera den organisation som fattar beslutet från den eller de som tar fram beslutsunderlaget för att öka legitimiteten. Det kan vara administrativt mer komplicerat med två separata organisationer men våra intryck från denna studie tyder på att denna nackdel uppvägs av de fördelar som uppnås.

    Det är en fördel om processerna för identifiering, utvärdering och beslut är så öppna som möjligt. Stor öppenhet i alla steg medför dock en stor arbetsbörda och kostnader. Frågan om öppenhet och medverkan från allmänheten förefaller vara en avvägning mellan tillräcklig grad av sekretess och öppenhet rörande både process och beslut för att uppnå legitimitet. Att vid ett eventuellt införande av NPK starta med en relativt sluten process där enbart besluten redovisas men sedan ha en tydlig ambition och plan för att bli mer öppen i hela processen efter hand kan vara en framkomlig väg. Vi bedömer att den värdegrund och det utvecklingsarbete av öppna prioriteringar som redan pågår i Sverige är av hög relevans för NPK. Vi ser därför inget behov av en särskild värdegrund för NPK, utöver den som blir resultatet av de pågående  prioriteringsdiskussionerna. Det är dock angeläget att ett eventuellt bildande av NPK föregås av framtagning av tydliga direktiv till NPK om hur den ska förhålla sig till och tillämpa riksdagens riktlinjer för prioriteringar.

    Med avseende på politisk involvering eller inte i besluten har det i samtliga länder vi har undersökt varit en tydlig politisk koppling till själva beslutet om införande eller inte av teknologin. Detta står i kontrast till hur det för närvarande fungerar i Sverige med t.ex. TLV, där besluten inte involverar politiker. I denna fråga verkar det snarare handla om att skapa ett system som gör att den kommitté eller person som ska fatta införandebeslutet har tillräckligt förtroende och legitimitet att förvalta denna uppgift. Det kan betyda att politiker inkluderas i en kommitté som befolkningsföreträdare eller representanter för den part som ansvarar för finansieringen. Lika väl kan det fungera med personer i kommittén som medverkar på personliga mandat, som har en adekvat kompetens och erfarenhet men också ett förtroende från andra att lösa uppgiften.

    Formen för ”Omprövning” är starkt sammankopplad med valet av andra strukturella komponenter. Vår utgångspunkt är dock att det bör finnas någon typ av omprövningsmekanism under processen samt efter beslut. Skulle det bli en myndighet som fattar bindande beslut på liknande sätt som TLV gör i dag bör det vara möjligt för företag att överklaga beslutet till domstol. I andra fall är det NPK som bör utveckla egna rutiner för omprövning på eget eller andras initiativ.

    Vi har i denna studie undersökt förutsättningar för etablering av en nationell prioriteringskommitté i Sverige för icke-farmakologiska sjukvårdsteknologier i hälso- och sjukvården. Arbetet har baserats på erfarenheter från länder med existerande system för beslut om införande av sjukvårdsteknologier samt diskussioner i Sverige med en referensgrupp samt styrgrupp för projektet. Vi har i vårt arbete identifierat tio viktiga komponenter för uppbyggnaden av en sådan kommitté och fört en diskussion kring dessa. Vi ser möjligheter och fördelar med att etablera en nationell prioriteringskommitté i Sverige för identifiering, utvärdering och prioritering vid beslut avseende införande av andra sjukvårdsteknologier än läkemedel i hälso- och sjukvården. För- och nackdelar med olika tänkbara lösningar har diskuterats i rapporten, medan de mer exakta formerna för en nationell prioriteringskommitté är en fråga för fortsatt utredning.

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    Förutsättningar för etablering av en nationell prioriteringskommitté i hälso- och sjukvården: Erfarenheter från andra länder
  • 3.
    Brodtkorb, Thor-Henrik
    et al.
    RTI Health Solutions, Lund.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Kalkan, Almina
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Metoder för värdering av QALYS2012In: QALY som effektmått inom vården: Möjligheter och begränsningar / [ed] Lars Bernfort, Linköping: Linköping University Electronic Press, 2012, p. 30-53Chapter in book (Other academic)
  • 4.
    Carlsson, Per
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Brodtkorb, Thor-Henrik
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Tinghög, Gustav
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Nationellt system för utvärdering, prioritering och införandebeslut av icke-farmakologiska sjukvårdsteknologier: en förstudie2010Report (Other academic)
    Abstract [en]

    The need for a national system to evaluate medical technologies other than pharmaceuticals is being considered. Several proposals advocate establishing a type of “Treatment Benefits Board”. To highlight problems and analyse the conditions for national assessments in this context, the National Board of Health and Welfare, the Medical Products Agency, the Swedish Council on Technology Assessment in Health Care (SBU), and the Dental and Pharmaceutical Benefits Agency (TLV) jointly appointed the Centre for Medical Technology Assessment (CMT) at Linköping University to conduct a preliminary study. The preliminary study should provide a foundation for the agencies to decide whether or not the issue needs to be investigated further.

    The preliminary study aims to develop background information concerning how Sweden and other countries currently assess, prioritise, and implement decisions involving new nonpharmaceutical health technologies. The basic questions addressed are:

    1. How can nonpharmaceutical technologies be defined and categorised for the purpose of setting parameters for an approval process?
    2. How is the current process of assessment, prioritisation, and approval in Sweden structured, focusing on SBU, the Medical Products Agency, the National Board of Health and Welfare, and TLV?
    3. How have other countries organised their systems for assessment, prioritisation, and approval of nonpharmaceutical technologies?

    Within the framework of the project it was not possible to conduct detailed, onsite studies of the healthcare systems in other countries. Hence, we relied on descriptions of other countries’ systems as reported in scientific articles, reports, and official documents available from various organisations and other sources via the Internet. In some instances the information was complemented by interviewing key individuals. The same applies to the descriptions of Swedish agencies. Information concerning the prevalence of various technologies was collected from official reports/reviews and registry data. We present information from six countries where we found sufficient information to preliminarily answer the questions we formulated in advance. The countries are Australia, New Zealand, England, Spain, Italy, Canada, and the USA.

    We draw the following conclusions from the preliminary study: It is relatively complicated to define nonpharmaceutical technologies and delineate the technologies that potentially could be subject to regulation. Our practical attempts to describe the technologies that SBU Alert has assessed show that:

    surgical and medical interventions dominate, but a relatively high number of screening programmes have also been assessed;

    • medical equipment and pharmaceuticals are the predominant input factors. Active implants and biological products are also relatively common. Assistive devices and dental products are seldom considered to be primary input factors;
    • most technologies are used primarily for treatment purposes. Diagnostic technologies are also relatively common.

    By removing pharmaceuticals from the equation and combining interventions and input factors, SBU Alert arrived at 18 different categories of health technologies that it assesses. The predominant combination is surgical intervention and biomedical equipment. This is followed by surgical intervention and insertion of active implants. In the report, we propose a way to define and classify technologies that we found to be appropriate for the purpose. This does not exclude pharmaceuticals. Rather, pharmaceuticals are included as one input factor among others.

    Another aim was to produce background information describing how Sweden and other countries currently assess, prioritise, and approve new nonpharmaceutical technologies. We identified several key components that we believe are worth considering in designing a national system for assessing, prioritising, and approving new nonpharmaceutical health technologies. These components are:

    • Organisational level – At what organisational level should the approval of nonpharmaceutical health technologies take place?
    • Scope – Should an all-inclusive or selective approach be taken towards inclusion/selection of health technologies for assessment?
    • Base package – Should there be a basic list showing what is financed with public funds, or is it sufficient to present only new decisions on the margin?
    • Diversity of actors – Should a single actor, or many actors, be responsible for assessment, prioritisation, and decisions regarding financing?
    • Fact producer – Who would be most appropriate to manage the factual information base?
    • Transparency – How transparent should one be in presenting the decisionmaking process and its results?
    • Political involvement – How politically independent should the decisions be?
    • Budgetary responsibility – Should the unit that recommends or decides on approval have a budgetary responsibility?
    • New and old – Should the decisions apply both to introducing new technology and phasing out old technology?
    • Fundamental values – Should there be an explicit set of fundamental values for prioritisation, and how should it be formulated?
    • Appeals – Should there be a mechanism to appeal decisions?

    To summarise, we see a trend in other countries towards an increasing level of assessment and prioritisation in decisions regarding the introduction of nonpharmaceutical health technologies. Our preliminary impression is that nearly every system that we studied continues to develop and remains “a work in progress”. For instance, in Australia and New Zealand official inquiries are under way to suggest or present proposals for improvement.

    Our studies of systems in different countries, although limited, indicate there is no perfect system to copy directly. The way in which the various systems are organised is somewhat related to how health care is organised in the respective countries and how many resources they have decided to dedicate to this purpose. The results from our preliminary study show, however, that several countries have more experience in “approving” nonpharmaceutical-based technologies than what we have in Sweden. The most interesting countries are England, New Zealand, Canada, and Australia. Spain could also be of interest. Hence, there is good reason to consider what might be the best way to analyse these countries’ systems in detail and complement this information with data from other nations that we were unable to include in the preliminary study, e.g. the Netherlands and Israel.

    To more rigorously analyse other systems, if this project is continued, investigators should probably start from one or more models for a Swedish mechanism. To arrive at one or more tentative models in this context, the county councils should be involved in the project. The format could be a workshop that engages representatives from public agencies, county councils, and professional associations, where they jointly outline conceivable models that could then be analysed and discussed in light of the experiences of other nations.

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    Nationellt system för utvärdering, prioritering och införandebeslut av icke-farmakologiska sjukvårdsteknologier – en förstudie
  • 5.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Health economic aspects of diabetic retinopathy2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    To ensure that the resources of the health care sector are used effectively, new technologies need to be evaluated before implementation to examine if they generate health outcomes at an acceptable cost. This information can be collected by performing health economic evaluations in which the costs and health outcomes of different technologies are compared. To estimate the effect on health care budgets, there is also a need for information about the prevalence of the specific disease. Health outcomes in health economic evaluations are often measured in quality-adjusted life years (QALYs), which are calculated by multiplying the remaining life years after an intervention by a weight representing the health-related quality of life (HRQoL) during those years.

    This thesis aims to provide deeper knowledge of the health economic aspects of diabetic retinopathy (DR), an eye complication that affects patients with diabetes and may in the worst case lead to blindness. The focus is on three empirical and two methodological health economic research questions. The empirical research areas cover prevalence, costs, and HRQoL related to patients with DR. The methodological research questions explore the performance of different methods for estimation of QALY weights. This is of interest since it has been argued that the most common methods for estimating QALY weights may not capture all relevant vision-related aspects of quality of life. The analyses comprehend the validity of different methods for estimating QALY weights among patients with DR and if the results of one of the specific methods for estimating QALY weights, the time trade-off (TTO) exercise, are affected by patients’ subjective life expectancy (SLE).

    The empirical results demonstrate that DR is seen in approximately 40% and 30% of patients with type I and type II diabetes respectively, indicating that the prevalence of DR has decreased in both of these patient groups. Healthcare costs vary considerably between different severity levels of the disease, being estimated at €26, €257, €216, and €433 per patient per year for background retinopathy, proliferative diabetic retinopathy (PDR), diabetic macular oedema (DMO), and PDR combined with DMO respectively. Blindness due to DR is associated with an increased use of transportation services, caregiving services, and assistive technologies as well as productivity losses. This suggests that preventing the progression of DR may lower healthcare costs. Patients with vision impairment due to DR have lowered HRQoL in various dimensions, but the diagnosis of DR in itself has only a limited effect on HRQoL.

    The results on the methodological research questions show that different methods for estimating QALY weights seem to give different results. In comparison to EQ-5D, the Health Utilities Index Mark 3 (HUI-3) is the most sensitive method for detecting differences in QALY weights due to DR, and if decisions are to be made based on values from the general public, it can be recommended for use in cost-utility analyses of interventions directed at DR. Neither of the direct methods, TTO and the visual analogue scale, seems to be sensitive to differences in visual function, and more research is needed concerning the role of vision in people’s responses to the TTO exercises. In TTO exercises with time frames based on actuarial life expectancy, the patients’ SLE has an effect on their willingness to trade off years for full health. Thus, applying time frames deviating from patients’ SLE may result in biased QALY weights. Such bias may appear stronger within patient populations than within the general public.

    In conclusion, this thesis offers estimates for prevalence, costs, and QALY weights that can be used in economic evaluations of interventions directed at DR and as benchmarks for future DR research in order to follow up consequences of changes in diabetes care. In addition, it demonstrates that the choice of method for estimating QALY weights may have an impact on whether an intervention is considered cost-effective.

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    Health economic aspects of diabetic retinopathy
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  • 6.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    The cost-effectiveness of foetal monitoring with ST analysis2008Report (Other academic)
    Abstract [en]

    How to allocate resources in the health care sector is academically dealt with within the subject of health economics. Economic evaluations are within this area used to compare the costs and effects of medical interventions with the purpose to help decision makers decide how to allocate resources.

    Oxygen deficiency in the foetus during birth can lead to severe life long injuries in the child. In high-risk deliveries, there is therefore considered necessary to use foetal surveillance with a scalp electrode and the choice is between surveillance with internal cardiotocography (CTG) and surveillance with ST analysis. The standard procedure is in most hospitals currently CTG, which records the foetal heart rate and the uterine contractions. The second strategy, in this thesis referred to as ST analysis, complements CTG with foetal electrocardiography (ECG) and ST analysis.

    The objective of this report is to from a societal perspective determine the costeffectiveness of using ST analysis in complicated deliveries, compared to the use of CTG alone. A cost-utility analysis was performed based on a probabilistic decision model incorporating the relevant strategies and outcomes. The costs and effects of the two different treatment strategies were compared in a decision tree. Discounted costs and quality-adjusted life-years (QALYs) were measured and simulated over a life-time perspective.

    The analysis resulted in an incremental effect of 0.005 QALYs for the ST analysis strategy, when compared to the CTG strategy. ST analysis was also associated with a €30 lower cost. Thus, CTG is dominated by the ST analysis strategy. The probability that ST analysis is the cost-effective alternative is high for all values of willingness-to-pay for a QALY, which means that a decision to implement the ST analysis strategy based on the results of this thesis would be surrounded by a low degree of uncertainty.

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    The Cost-Effectiveness of Foetal Monitoring with ST Analysis
  • 7.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Swedish Council on Health Technology Assessment (SBU), Stockholm.
    Arnberg, Karl
    The Dental and Pharmaceutical Benefits Agency (TLV) Stockholm.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Liliemark, Jan
    Swedish Council on Health Technology Assessment (SBU), Stockholm and The county councils' group on new drug therapies (NLT), The Swedish Association of Local Authorities and Regions (SALAR), Stockholm.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences. Swedish Council on Health Technology Assessment (SBU), Stockholm.
    The impact of health economic evaluations in Sweden.2014In: Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, ISSN 2212-0289, Vol. 108, no 7, p. 375-82Article in journal (Refereed)
    Abstract [en]

    The responsibility for healthcare in Sweden is shared by the central government, county councils and municipalities. The counties and municipalities are free to make their own prioritizations within the framework of the state healthcare laws. To guide prioritization of healthcare resources in Sweden, there is consensus that cost-effectiveness constitutes one of the three principles. The objective of this paper is to describe how cost-effectiveness, and hence health economic evaluations (HEE), have a role in pricing decisions, reimbursement of pharmaceuticals as well as the overall prioritization and allocation of resources in the Swedish healthcare system. There are various organizations involved in the processes of implementing health technologies in the Swedish healthcare system, several of which consider or produce HEEs when assessing different technologies: the Dental and Pharmaceutical Benefits Agency (TLV), the county councils' group on new drug therapies (NLT), the National Board of Health and Welfare, the Swedish Council on Health Technology Assessment (SBU), regional HTA agencies and the Public Health Agency of Sweden. The only governmental agency that has official and mandatory guidelines for how to perform HEE is TLV (LFNAR 2003:2). Even though HEEs may seem to have a clear and explicit role in the decision-making processes in the Swedish healthcare system, there are various obstacles and challenges in the use and dissemination of the results.

  • 8.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Bourghardt Peebo, Beatrice
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Department of Ophthalmology UHL/MH.
    Wiréhn, Ann-Britt
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Rosenqvist, Ulf
    Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Department of Medical Specialist.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Health-related quality of life profiles of patients with diabetic retinopathyManuscript (preprint) (Other academic)
    Abstract [en]

    Purpose: There are various instruments for estimating health-related quality of life (HRQoL) in patients with diabetic retinopathy (DR). However, if the results are to be compared with those for other diseases, it is essential to use measures that are applicable to all disease areas. The aim of this study was to explore the HRQoL profiles of patients with DR using two generic multi-attribute instruments, the Health State Utilities Index Mark 3 (HUI-3) and the EQ-5D questionnaire, and to investigate these questionnaires’ sensitivity to differences in HRQoL due to DR.

    Methods: The study population comprised 166 Swedish diabetes patients diagnosed with DR at different severities. Patients were interviewed over the telephone using HUI-3 and EQ-5D. The vision-specific National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25) was also included, to give an empirical framework for the results of the generic instruments. Linear and logistic regression models were used to adjust for possible confounders.

    Results: Patients with vision impairment (VI) reported lower scores in Vision, Ambulation, and Pain in HUI-3 and more problems with Usual activities and Anxiety/depression in EQ-5D. However, even though NEI VFQ-25 showed a negative association between DR severity and Mental health and Near activities, neither EQ-5D nor HUI-3 identified a negative relationship between DR severity and HRQoL.

    Conclusion: The generic instruments show lowered HRQoL for patients with VI in various dimensions but were not sensitive to decrements related to the diagnosis of DR alone. The questionnaire of HUI-3 was more sensitive than EQ-5D to differences in HRQoL due to DR-related VI.

  • 9.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Brodtkorb, Thor-Henrik
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Nelson, Nina
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Pediatrics. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Paediatrics in Linköping.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    The long-term cost-effectiveness of fetal monitoring during labour: a comparison of cardiotocography complemented with ST analysis versus cardiotocography alone2008In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 115, p. 1676-1687Article in journal (Refereed)
    Abstract [en]

    Objective: To assess the cost-effectivness of the use of cardiotocography (CTG) complemented with fetal electrocardiography and ST analysis compared with the use of CTG alone in term deliveries when a decision has been made to use fetal monitoring with a scarlp electrode. Design: A cost-effectiveness analysis based on a probabilistic decision model incorporating relevant strategies and lifelong outcomes. Setting: Maternity wards in Sweden. Population: Women with term fetuses after a clinical decision had been made to apply a fetal scalp electrode for internal CTG. Methods: A decision model was used to compare the costs and effects of two different treatment strategies. Baseline estimates were derived from the literature. Discounted costs and quality-adjusted life years (QALYs) were simulated over a lifetime horizon using a probabilistic model. Main outcome measures: QALYs, incremental costs, and cost per QALY gained expressed as incremental cost-effectiveness ratio (ICER). Results: The analysis found an incremental effect of 0.005 QALYs for ST analysis compared with CTG; the ST analysis strategy was also moreover associated with a -56 decrease in costs, thus dominating the CTG strategy. The probability that ST analysis is cost-effective in comparison with CTG is high, irrespective of the willingness-to-pay value for a QALY. Conclusions: Compared with CTG alone, ST analysis is cost-effective when used in term high-risk deliveries in which there is a need for internal fetal monitoring.

  • 10.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Gerber-Grote, Andreas
    Institut für Qualität und Wirtschaftlichkeit Gesundheitswes, Germany.
    Ghabri, Salah
    Department of Economic and Public Health Evaluation, Haute Autorite Sante, France.
    Hamers, Francoise F.
    Department of Economic and Public Health Evaluation, Haute Autorite de Sante, France.
    Prevolnik Rupel, Valentina
    Institute for Economic Research, Slovenia.
    Slabe-Erker, Renata
    Institute for Econ Research, Slovenia.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Agency Health Technology Assessment and Assessment, Sweden.
    Is There a European View on Health Economic Evaluations? Results from a Synopsis of Methodological Guidelines Used in the EUnetHTA Partner Countries2016In: PharmacoEconomics (Auckland), ISSN 1170-7690, E-ISSN 1179-2027, Vol. 34, no 1, p. 59-76Article in journal (Refereed)
    Abstract [en]

    The objectives of this study were to review current methodological guidelines for economic evaluations of all types of technologies in the 33 countries with organizations involved in the European Network for Health Technology Assessment (EUnetHTA), and to provide a general framework for economic evaluation at a European level. Methodological guidelines for health economic evaluations used by EUnetHTA partners were collected through a survey. Information from each guideline was extracted using a pre-tested extraction template. On the basis of the extracted information, a summary describing the methods used by the EUnetHTA countries was written for each methodological item. General recommendations were formulated for methodological issues where the guidelines of the EUnetHTA partners were in agreement or where the usefulness of economic evaluations may be increased by presenting the results in a specific way. At least one contact person from all 33 EUnetHTA countries (100 %) responded to the survey. In total, the review included 51 guidelines, representing 25 countries (eight countries had no methodological guideline for health economic evaluations). On the basis of the results of the extracted information from all 51 guidelines, EUnetHTA issued ten main recommendations for health economic evaluations. The presented review of methodological guidelines for health economic evaluations and the consequent recommendations will hopefully improve the comparability, transferability and overall usefulness of economic evaluations performed within EUnetHTA. Nevertheless, there are still methodological issues that need to be investigated further.

  • 11.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Krol, Marieke
    Department of Health Policy and Management, Erasmus University, Rotterdam.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    The impact of patients' subjective life expectancy on time trade-off valuations2013In: Medical decision making, ISSN 0272-989X, E-ISSN 1552-681X, Vol. 33, no 2, p. 261-270Article in journal (Refereed)
    Abstract [en]

    Background. Quality-adjusted life-year (QALY) calculations in economic evaluations are typically based on general public or patient health state valuations elicited with the time tradeoff method (TTO). Such health state valuations elicited among the general public have been shown to be affected by respondents subjective life expectancy (SLE). This suggests that TTO exercises based on time frames other than SLE may lead to biased estimates. It has not yet been investigated whether SLE also affects patient valuations. Objective. To empirically investigate whether patients SLE affects TTO valuations of their current health state. Methods. Patients with different severities of diabetic retinopathy were asked in a telephone interview to value their own health status using TTO. The TTO time frame (t) presented was based on age- and sex-dependent actuarial life expectancy. Patients were then asked to state their SLE. Simple and multiple regression techniques were used to assess the effect of the patients SLE on their TTO responses. Results. In total, 145 patients completed the telephone interview. Patients TTO values were significantly influenced by their SLE. The TTO value decreased linearly with every additional year of difference between t and the patients SLE; that is, patients were more willing to give up years the shorter their SLE compared with t. Conclusion. Patients SLE influenced their TTO valuations, suggesting that respondents SLE may be the most appropriate time frame to use in TTO exercises in patients. The use of other time periods may bias the TTO valuations, as the respondents may experience the presented time frame as a gain or a loss. The effect seems to be larger in patient valuations than in general public valuations.

  • 12.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Council Health Technology Assessment SBU, Sweden.
    Lintamo, Laura
    Swedish Council Health Technology Assessment SBU, Sweden.
    Hultcrantz, Monica
    Swedish Council Health Technology Assessment SBU, Sweden; Karolinska Institute, Sweden.
    Jacobson, Stella
    Swedish Council Health Technology Assessment SBU, Sweden; Karolinska Institute, Sweden.
    Levi, Ragnar
    Swedish Council Health Technology Assessment SBU, Sweden.
    Munthe, Christian
    University of Gothenburg, Sweden.
    Tranaeus, Sofia
    Swedish Council Health Technology Assessment SBU, Sweden; Malmö University, Sweden; Karolinska Institute, Sweden.
    Ostlund, Pernilla
    Swedish Council Health Technology Assessment SBU, Sweden; Malmö University, Sweden.
    Sandman, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. University of Boras, Sweden.
    FRAMEWORK FOR SYSTEMATIC IDENTIFICATION OF ETHICAL ASPECTS OF HEALTHCARE TECHNOLOGIES: THE SBU APPROACH2015In: International Journal of Technology Assessment in Health Care, ISSN 0266-4623, E-ISSN 1471-6348, Vol. 31, no 3, p. 124-130Article in journal (Refereed)
    Abstract [en]

    Objectives: Assessment of ethical aspects of a technology is an important component of health technology assessment (HTA). Nevertheless, how the implementation of ethical assessment in HTA is to be organized and adapted to specific regulatory and organizational settings remains unclear. The objective of this study is to present a framework for systematic identification of ethical aspects of health technologies. Furthermore, the process of developing and adapting the framework to a specific setting is described. Methods: The framework was developed based on an inventory of existing approaches to identification and assessment of ethical aspects in HTA. In addition, the framework was adapted to the Swedish legal and organizational healthcare context, to the role of the HTA agency and to the use of non-ethicists. The framework was reviewed by a group of ethicists working in the field as well as by a wider set of interested parties including industry, interest groups, and other potential users. Results: The framework consists of twelve items with sub-questions, short explanations, and a concluding overall summary. The items are organized into four different themes: the effects of the intervention on health, its compatibility with ethical norms, structural factors with ethical implications, and long term ethical consequences of using the intervention. Conclusions: In this study, a framework for identifying ethical aspects of health technologies is proposed. The general considerations and methodological approach to this venture will hopefully inspire and present important insights to organizations in other national contexts interested in making similar adaptations.

  • 13.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Peebo, Bourghardt B.
    Ryhov County Hospital.
    Wiréhn, Ann-Britt
    Linköping University, Department of Department of Health and Society, Tema Health and Society. Linköping University, Faculty of Arts and Sciences.
    Rosenqvist, U.
    Motala Hospital.
    Levin, Lars-Åke
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    QUALITY-ADJUSTED LIFE-YEAR (QALY) WEIGHTS ASSOCIATED WITH DIFFERENT SEVERITY LEVELS OF DIABETIC RETINOPATHY in VALUE IN HEALTH, vol 13, issue 7, pp A297-A2972010In: VALUE IN HEALTH, Blackwell Publishing Ltd , 2010, Vol. 13, no 7, p. A297-A297Conference paper (Refereed)
    Abstract [en]

    n/a

  • 14.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Wiréhn, Ann-Britt
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Bourghardt Peebo, Beatrice
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Ophthalmology in Linköping.
    Rosenqvist, Ulf
    Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    QALY weights for diabetic retinopathy: a comparison of health state valuations with HUI-3, EQ-5D, EQ-VAS, and TTO.2012In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 15, no 3, p. 475-484Article in journal (Refereed)
    Abstract [en]

    Objective: To estimate quality-adjusted life-year weights for patients with diabetic retinopathy by using various methods and to investigate the empirical validity of the different measures.

    Methods: The study population comprised 152 patients with diabetes in Östergötland County, Sweden. Participants were interviewed by telephone by using the time trade-off (TTO) method and a visual analogue scale (EQ-VAS) (direct valuations) as well as the EuroQol five-dimensional questionnaire (EQ-5D) and the health utilities index mark 3 (HUI-3) (indirect valuations). The quality-adjusted life-year weights were adjusted for potential confounders by using analysis of covariance. The empirical validity of the measures was examined by testing their ability to detect hypothetical differences between severity levels of diabetic retinopathy and by investigating the correlation between the measures and the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25).

    Results: All measures detected significant differences in scores between patient groups classified according to visual impairment in the better eye (analysis of covariance, P < 0.05), but only HUI-3 and EQ-VAS detected significant differences between patient groups classified according to visual impairment or pathological progression in the worse eye. HUI-3 recorded a difference of 0.43 in values between normal vision and blindness in the better eye, which was more than twice the differences captured by the other measures (0.15–0.20). In addition, HUI-3 showed the highest correlation with NEI VFQ-25 (r = 0.54; P < 0.001).

    Conclusions: In cost-utility analyses, the choice of quality-adjusted life-year measure may affect whether an intervention is considered cost-effective. Furthermore, if decisions are to be based on values from the general public, HUI-3 can be recommended for cost-utility analyses of interventions directed at diabetic retinopathy.

  • 15.
    Heintz, Emelie
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Wiréhn, Ann-Britt
    Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
    Peebo Bourghardt, Beatrice
    Östergötlands Läns Landsting, Reconstruction Centre, Department of Ophthalmology UHL/MH.
    Rosenqvist, U
    Motala Hospital, Sweden.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Prevalence and healthcare costs of diabetic retinopathy: a population-based register study in Sweden2010In: Diabetologia, ISSN 0012-186X, E-ISSN 1432-0428, Vol. 53, no 10, p. 2147-2154Article in journal (Refereed)
    Abstract [en]

    Aims/hypothesis

    The aim of the present study was to estimate the prevalence and healthcare costs of diabetic retinopathy (DR).

    Methods

    This population-based study included all residents (n = 251,386) in the catchment area of the eye clinic of Linköping University Hospital, Sweden. Among patients with diabetes (n  = 12,026), those with and without DR were identified through register data from both the Care Data Warehouse in Östergötland, an administrative healthcare register, and the Swedish National Diabetes Register. Healthcare cost data were elicited by record linkage of these two registers to data for the year 2008 in the Cost Per Patient Database developed by Östergötland County Council.

    Results

    The prevalence of any DR was 41.8% (95% CI 38.9–44.6) for patients with type 1 diabetes and 27.9% (27.1–28.7) for patients with type 2 diabetes. Sight-threatening DR was present in 12.1% (10.2–14.0) and 5.0% (4.6–5.4) of the type 1 and type 2 diabetes populations respectively. The annual average healthcare cost of any DR was €72 (€53–91). Stratified into background retinopathy, proliferative DR, maculopathy, and the last two conditions combined, the costs were €26 (€10–42), €257 (€155–359), €216 (€113–318) and €433 (€232–635) respectively. The annual cost for DR was €106 000 per 100,000 inhabitants.

    Conclusions

    This study presents new information on the prevalence and costs of DR. Approximately one-third of patients with diabetes have some form of DR. Average healthcare costs increase considerably with the severity of DR, which suggests that preventing progression of DR may lower healthcare costs.

  • 16.
    Levin, Lars-Åke
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Andersson, David
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Anell, Anders
    Lunds universitet.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Hoffman, Mikael
    Östergötlands Läns Landsting. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
    Schmidt, Andrea
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Styrformer för effektiv läkemedelsanvändning2010Report (Other academic)
    Abstract [sv]

    Rapporten Styrformer för effektiv läkemedelsanvändning har tagits fram av Institutionen för medicin och hälsa vid Linköpings universitet. Utgångspunkten var ett uppdrag som givits av Socialdepartementet och Sveriges kommuner och landsting inom arbetet med Handlingsplan för effektivare läkemedelsanvändning. Handlingsplanen presenterades av en arbetsgrupp i mars 2009. Rapportens resultat kommer att integreras i arbetet med en nationell läkemedelsstrategi.

    Syftet med rapporten är att kartlägga olika styrformer för läkemedelsanvändning i landstingen och analysera deras betydelse för rättvisa och effektivitet i läkemedelsanvändningen. Ett delsyfte med studien, som görs för första gången, är att starta utvecklingen av metodik för den här typen av analys.

    Studien består av tre delar. Den första delen är en kartläggning av landstingens styrning av läkemedelsförmånerna. I del två redovisas mått (indikatorer) som beskriver utfallet i form av läkemedelsanvändningen i olika landsting. I del tre analyseras skillnader i kunskaps- och ekonomistyrning i relation till skillnader i läkemedelsanvändning i form av de utfallsmått som beskrivits i del två.

    Material till kartläggningen har insamlats via enkät till samtliga 21 landsting och enkätsvaren har sedan följts upp per telefon. I enkäten efterfrågades hur styrningen fungerade år 2008 och år 2005.

    • Decentraliseringsgraden i landstingen har ökat. Kostnadsansvaret låg på klinik- och vårdcentralsnivå i tolv landsting (9 landsting år 2005), på en mellannivå i fem landsting (7 landsting år 2005) och centralt i fyra landsting år 2008 (5 landsting år 2005).
    • Fler landsting valde en förskrivarbaserad modell (9 landsting) istället för en befolkningsbaserad modell (8 landsting) 2008. Tre år tidigare var det istället något fler som hade valt den befolkningsbaserade modellen (10 landsting respektive 6 landsting med förskrivarbaserad modell).
    • Tio landsting hade en integrerad hälso- och sjukvårdsbudget år 2008 (8 landsting 2005). Sju landsting hade en separat läkemedelsbudget (8 landsting 2005).
    • Oavsett om landstingen hade en separat läkemedelsbudget eller en integrerad hälso- och sjukvårdsbudget var det vanligast att över- och underskott på lokal nivå hanterades inom den totala budgetramen för hälso- och sjukvård. Några landsting hade utvecklat olika incitamentsmodeller där det fanns möjlighet att ta del av hela eller delar av eventuellt överskott om vissa förskrivningsmål/produktionsmål/ kvalitetsmål uppfylldes.
    • Frågan om hur under- och överskott hanteras i praktiken upplevdes som svår att besvara av kontaktpersonerna. Det finns en osäkerhet om vilka formella regler som egentligen gäller, vilket påverkat svaren.
    • Kunskapsstöd i form av läkemedelskommitténs rekommendationslista och producentobunden information fanns i alla landsting. Representanter för ansåg generellt att deras olika former av förskrivarstöd fungerade minst lika bra som motsvarande stöd i övriga landsting. Ett undantag var IT-baserat förskrivarstöd inom privat vård där många landsting ansåg att det egna stödet fungerade sämre än i andra landsting.
    • Vid en rangordning av de tre viktigaste stödformerna anses IT-baserat förskrivarstöd vid sjukhus som allra viktigast följt av läkemedelskommitténs rekommendationslista samt producentobundeninformation.
    • Tidigare kartläggningar visar att landstingen över tiden hanterat kostnadsansvaret för öppenvårdsläkemedel på olika sätt. Jämfört med en tidigare undersökning från 2002 har decentraliseringsgraden inomlandstingen år 2008 ökat markant[1, 2].

    Analysdelen – med sammanvägning av enkätresultat och utfall av indikatorer i skilda dimensioner – visar att:

    • Landstingens struktur i form av förekomst av universitet och landstingets storlek är den faktor som påverkar läkemedelsanvändningen mest.
    • Landsting som infört ett decentraliserat kostnadsansvar jämfört med övriga landsting:
    1. har inte mindre volym (DDD/invånare) men lägre kostnad per invånare.
    2. har bättre följsamhet till läkemedel som rekommenderas av läkemedelskommittéer.
    3. avvek däremot inte från övriga landsting vad gällde andel patienter som fick kostnadseffektiv behandling, olämplig förskrivning inklusive polyfarmaci, användning av nya läkemedel med stor innovationshöjd samt jämlikhet. Detta kan eventuellt förklaras av otillräcklig statistisk styrka för att finna skillnader mellan grupperna.
    • Kunskapsstyrning har i denna studie en liten påverkan på  läkemedelsanvändningen. Det beror bland annat på att:
    1. kunskapsstyrning är starkt korrelerad med struktur vilket gör analysen svårtolkad.
    2. kunskapsstyrning är svår att operationalisera och mäta.
    3. kunskapsvariablernas variation är dessutom liten mellan landstingen.
    • IT-stöd i form av gemensam läkemedelslista samvarierar emellertid med kvalitetsvariabeln ”färre interaktioner”.

    Ett huvudresultat är att landsting med ett decentraliserat kostnadsansvar för läkemedel samtidigt hade lägre kostnader för läkemedel i öppen vård per invånare och högre följsamhet till rekommendationer utan att volymen läkemedel avvek från övriga landsting.

    Då detta är en epidemiologisk studie kan samvariationer beskrivas. Däremot kan studien inte visa om samvariationerna också är uttryck för orsakssamband, eller i vilken riktning ett eventuellt orsakssamband skulle gå. Inte heller kan studien kontrollera för okända faktorer som kan tänkas påverka båda de variabler som samvarierar. Inventeringen och analysen av existerande indikatorer på effektiv och jämlik läkemedelsanvändning visar på en mängd metodproblem som försvårar studier av samband mellan styrformer och utfall. Det är därför angeläget att arbetet med att utveckla valida effektivitetsindikatorer fortsätter.

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    Styrformer för effektiv läkemedelsanvändning
  • 17.
    Sandman, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Statens beredning för medicinska utvärderingar (SBU).
    ”Är du nyttig lille vän?”: om produktionspåverkan, konsumtionspåverkan och den svenska etiska plattformen för prioriteringar2013In: Prioriteringar i hälso- och sjukvården / [ed] Ingalill Rahm Hallberg, Lund: Region Skånes etiska råd , 2013, p. 63-93Chapter in book (Other academic)
    Abstract [sv]

    I Sverige har vi en etisk plattform som skall styra de prioriteringar som görs inom hälso- och sjukvården. Denna plattform innehåller tre principer: människovärdesprincipen, behovs-solidaritetsprincipen och kostnadseffektivitetsprincipen (se nedan). När man beräknar kostnadseffektiviteten för en viss insats inom hälso- och sjukvården så tar man dels med direkta kostnader (dvs. sådana kostnader som är direkt förknippade med sjukvården), dels väger man in indirekta kostnader (exempelvis kostnader för produktionspåverkan och framtida konsumtion) – dvs. kostnader som faller på en annan sektor i samhället än hälso- och sjukvården. Under senare år har detta väckt en del diskussion framförallt eftersom man menar att det är diskriminerande gentemot äldre eller grupper som inte kan återgå i arbete. Detta då åtgärder som riktas till dessa grupper inte kan ge samma produktionsintäkter i form av återgång till arbete som åtgärder som riktar sig till yngre arbetsföra individer. Som konsekvens blir deras framtida konsumtion endast en kostnad för samhället utan någon motsvarande vinst i form av ökad produktion. I denna uppsats analyserar vi huruvida det är etiskt försvarbart att väga in produktionspåverkan och framtida konsumtion när vi prioriterar hälso- och sjukvårdsinsatser1 utifrån den svenska etiska plattformen.

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  • 18.
    Tranaeus, U.
    et al.
    Karolinska Institute, Sweden.
    Heintz, Emelie
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Swedish Council Health Technology Assessment, Sweden.
    Johnson, U.
    Halmstad University, Sweden.
    Forssblad, M.
    Karolinska Institute, Sweden.
    Werner, S.
    Karolinska Institute, Sweden.
    Injuries in Swedish floorball: a cost analysis2017In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 27, no 5, p. 508-513Article in journal (Refereed)
    Abstract [en]

    The epidemiology of sport injuries is well documented. However, the costs are rarely discussed. Previous studies have presented such costs in specific sports or localization. No study has investigated the costs related to injuries in elite floorball. Thus, the aim of this study was to estimate cost of injuries in Swedish elite floorball players. During 1year, 346 floorball players were prospectively followed. All time-loss injures were recorded. The injured players were asked to complete a questionnaire regarding their costs tied to the injury. Mean costs were calculated by multiplying the total resource use with the collected unit costs and dividing these total costs with the number of injuries as well as players. The results showed that the average cost per injury increased with the level of severity and ranged from 332 to 2358 Euros. The mild and moderate overuse injuries were costlier than the corresponding traumatic injuries. However, the severe traumatic injuries were associated with higher costs than overuse injuries. Knee injuries were the costliest. Our results indicate that there are costs to be saved, if floorball injuries can be avoided. They should be of interest to decision makers deciding whether to invest in preventive interventions.

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