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  • 1.
    Alwin, Jenny
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundqvist, Martina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundqvist, Martina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Utvärdering av försöksverksamhet med service- och signalhundar2014Report (Other academic)
    Abstract [sv]

    Denna rapport redovisar utvärderingen av en försöksverksamhet med ser-vice- och signalhundar som bedrevs mellan år 2009 och 2014. Utvärderingen inkluderar servicehundar, signalhundar samt alarmerande servicehundar (epilepsihundar och diabeteshundar). Totalt 56 ekipage (förare samt hund) ingick i utvärderingsstudien. Data i studien samlades in före samt efter genomgången service- och signalhundsutbildning. Syftet med utvärderingen är att studera hur certifierade service- och signalhundar påverkar förarnas behov av offentliga stödinsatser och de totala samhällskostnaderna. Dessutom studerades hur service- och signalhundar påverkar förarna med avseende på hälsorelaterad livskvalitet, välbefinnande, självförtroende och fysisk aktivitet samt om användningen av service- och signalhundar är kostnadseffektiv ur ett samhällsperspektiv.

      Resultat och slutsatser

    • Service- och signalhundar minskar i genomsnitt förarnas behov av offentliga stödinsatser med 197 000 kronor (6 procent) under en tioårsperiod.
    • Livskvaliteten för personer med behov av service- och signalhundar är låg jämfört med den allmänna populationen i Sverige. Studien visar på en förbättring i livskvaliteten och välbefinnandet för förare med en certifierad hund.
    • Förarnas grad av fysisk aktivitet ökade med en certifierad hund och majoriteten av dem angav att de ökat sin tid utanför hemmet samt att de även ökat sin tid för att delta i sociala aktiviteter tack vare hunden.
    • Förarnas negativa emotionella upplevelser minskar med en certifierad hund.
    • Förarna beskriver själva den certifierade hunden som ett viktigt verktyg för ökad självständighet och trygghet.
    • Den hälsoekonomiska modellen som analyserar kostnadseffektiviteten visar att ett innehav av en certifierad hund är ett dominant alternativ jämfört med att inte ha en certifierad hund. Detta innebär att kostnaderna ur ett samhällsperspektiv under en tioårsperiod är lägre (-103 000 kronor) samtidigt som effekterna i form av vunna QALY (kvalitetsjusterade levnadsår) är högre (+0,15).
    • Finansieringsanalysen visar att förare som har certifierade hundar sparar resurser åt alla aktörer (stat, kommun och landsting) men får själva ökade utgifter på grund av hunden.
    • Studien baseras på ett lågt antal observationer (56 ekipage). Det i kombination med att det är en stor spridning i resursförbrukningen mellan ekipagen medför att det finns en statistisk osäkerhet i resultaten. Slutsatserna bedöms dock som rimliga eftersom de är samstämmiga.
  • 2.
    Eriksson, Thérèse
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lundqvist, Martina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hälsoekonomisk effektanalys av forskning inom programmet Innovationer för framtidens hälsa2014Report (Other academic)
    Abstract [sv]

    Det övergripande syftet i denna rapport är att undersöka vad de forskningsprojekt som erhållit medel från VINNOVA har resulterat i och om resultaten har omsatts i praktiken inom hälsooch sjukvården eller kommersiellt, men också att beräkna hälsoekonomiska effekter när det är möjligt. När det gäller programmet Innovationer för framtidens hälsa inkluderades de projekt som erhållit medel från VINNOVA mellan åren 2009 och 2013 och som avslutats fram till augusti 2013. Dessa uppgick till 19 stycken och spänner över ett brett spektra av medicinska och hälsorelaterade tillämpningsområden och befinner sig i olika faser i forskningen. Projekten representerar en blandning av tillämpad forskning och forskning på en mer grundläggande nivå.

    Projektens utveckling har analyserats utifrån en innovations- och spridningsprocess, om det finns visade hälsoeffekter och hälsoekonomiska effekter analyseras även dessa. Alla projekt, med undantag från ett, har genererat minst en produkt. Fyra forskningsprojekt har genererat två produkter, därför har totalt 23 produkter klassificerats. Projektens innovationsprocess har analyserats utifrån en innovationstrappa bestående av sju steg. Typvärdet för projektens förflyttning uppgår till ett steg, totalt har nio projekt förflyttat sig ett steg. Det därefter mest frekventa värdet är två steg, totalt åtta projekt har förflyttat sig två steg. Den största förflyttningen var fem steg, från steg ett till steg sex. Utfallet för projektens spridningsprocess gällande hälsoekonomiska effekter beskrivs nedan:

    • Två projekt har resulterat i en etablerad produkt med avläsbara hälsoeffekter. (A)
    • Tre projekt har resulterat i en produkt som befinner sig i en tidig spridningsfas i hälso- och sjukvården. (C)
    • Tio projekt har resulterat i en produkt som hittills endast använts i forskningssyfte eller för forskningsändamål. (D)
    • Sex projekt har resulterat i kunskaper som med stor sannolikhet kan vidareförädlas till en produkt. (E)
    • Två projekt har resulterat i kunskaper som har öppnat upp för vidare/fördjupad forskning. (F)

    Inget av de studerade projekten har klassificerats i kategori B eller G, dvs. forskning som lett till en etablerad produkt men utan hälsoeffekter respektive forskning som inte bidragit till en produkt eller kunskaper som kommer att leda till en produkt. Majoriteten av projekten har resulterat i en produkt som hittills endast använts i forskningssyfte för forskningsändamål eller en färdig produkt avsedd att användas endast för forskningsändamål.

    Hälsoekonomiska analyser genomfördes på grundval av de två projekt som genererat hälsoeffekter. Uppskattningen av hälsoekonomisk effekt bör tolkas med försiktighet då beräkningarna är baserade på antaganden med många osäkerheter.

    • Screeningsinstrumentet WINROP är ett datorprogram som avgör vilka nyfödda barn som ligger i riskzonen för att utveckla ögonsjukdomen prematuritetsretinopati (ROP). En fördel med metoden är att, för barnen, besvärande ögonundersökningar kan undvikas. Baserat på antalet för tidigt födda barn år 2012, skulle även en kostnadsbesparing på cirka 2,6 miljoner kronor per år kunna åstadkommas.
    • Lungtransplantationssystemet Vivoline LS1 används för att utvärdera, rekonditionera och förvara lungor inför en transplantation. Systemet möjliggör att fler lungor kan bli tillgängliga för transplantation. Uträkningar pekar på att Vivoline LS1 skulle kunna generera en samhällsvinst på mellan 9 och 51 miljoner kronor per år. Osäkerheten i beräkningen beror på stora variationer i kostnader för en lungtransplantation vilken kan bero på komplexiteten i processen.

    Vidare gjordes en långtidsuppföljning av sju projekt som bedömdes lovande i en tidigare effektanalys från 2009. Ingen av de inkluderade teknologierna hade avvecklats och de flesta hade genomgått en teknisk och marknadsmässig utveckling. Ett projekt fick vid uppföljningen klass A istället för B.

    Analysen visar att det går att härleda forskningens effekter och att effekterna blir tydligare med tiden. Uppföljningen av de avslutade projekten inom programmet Innovationer för framtidens hälsa visar en viss måluppfyllelse av programmets kortsiktiga mål och det ser lovande ut även för de långsiktiga.

    Slutsatser

    • Sjutton av de nitton projekten i programmet Innovationer för framtidens hälsa har efter kort tid utvecklats positivt utifrån ett innovationsperspektiv.
    • Tio projekt har resulterat i en eller flera produkter som hittills använts i forskningssyfte dvs. produkterna är fortfarande föremål för kliniska prövningar eller är enbart avsedda att användas för forskningsändamål.
    • Två projekt har visat hälsoekonomiska effekter.
    • Finansieringen från VINNOVA upplevdes ha haft stor betydelse för projekten.
    • I långtidsuppföljningen av projekt som tidigare erhållit medel från VINNOVA och NUTEK har projekten utvecklats vidare sedan den tidigare uppföljningen och det finns exempel på hälsoekonomiska effekter.
    • Det är fördelaktigt att beskriva forskningsprojekten utifrån både ett effekt- och innovationsprocessperspektiv.
    • Ett bättre stöd för kommersialisering och implementering efterlyses.
  • 3.
    Lundqvist, Martina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Hälsoekonomisk analys av hemtandvård jämfört med tandvård på stationära kliniker för äldre vid särskilda boenden2013Report (Other academic)
    Abstract [en]

    Background: The number and age of the elderly population in Sweden is increasing, and the cost of dental care is expected to increase  substantially during the next decades. Improved dental status among elderly, has led to a majority of elderly with most of their own teeth relatively intact, often in combination with dental restorations, or prosthetics (e.g. crowns, bridges, dental implants). Ageing leads to increased morbidity, and hospitalization or dependence on the care of others lead to a risk for severe deterioration of oral health. The county councils subsidize dental care for elderly nursing home residents in Sweden. Elderly nursing home residents are entitled to limited dental care, for the same fixed patient fee as in outpatient health care. The patient is free to choose provider of dental care. Dental care is usually offered at stationary dental clinics, but domiciliary dental care is an alternative.

    Purpose: The aim was to analyze economic consequences of domiciliary dental care, compared to dentistry at a stationary clinic, for elderly nursing home residents in Sweden.

    Methods: Nursing home staff, officials at county councils, and academic experts in geriatric dentistry, were interviewed. Cost analyses and costeffectiveness analyses were done. The market of dental care was analyzed from a societal perspective, to identify aspects of importance for the choice of stationary clinic or domiciliary dental care for elderly nursing home residents. Risks of asymmetric information between the involved participants (i.e. county council, dental care providers, municipalities, nursing homes, and patients) were analyzed, together with respective incentives to gain benefits.

    Results: For elderly nursing home residents the mean societal cost of domiciliary dental care was lower compared to dental care at stationary dental clinic. Domiciliary dental care was expected to increase the quality of life, and was cost effective compared to dental care at a stationary clinic.

    Conclusions: Domiciliary dental care has lower societal cost, is expected to improve the quality of life, and is cost-effective compared to dental care at stationary clinics, for elderly nursing home residents in Sweden. Since the prerequisites for seeking dental care among the elderly differ, it is important that dental care can be provided at different settings. Increased collaboration between the involved participants is needed in order to improve the efficiency and cost-effectiveness of dental care for elderly nursing home residents.

  • 4.
    Lundqvist, Martina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Davidson, Thomas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Ordell, Sven
    Region Östergötland, Public Dental Health Care.
    Sjöstrom, O.
    Oral Care AB, Sweden.
    Zimmerman, M.
    Oral Care AB, Sweden.
    Sjogren, P.
    Oral Care AB, Sweden.
    Health economic analyses of domiciliary dental care and care at fixed clinics for elderly nursing home residents in Sweden2015In: Community Dental Health, ISSN 0265-539X, Vol. 32, no 1, p. 39-43Article in journal (Refereed)
    Abstract [en]

    Objectives: Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic. Methods: A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses. Results: The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting. Conclusions: Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.

  • 5.
    Lundqvist, Martina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Ennab Vogel, Nicklas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Effects of eating breakfast and school breakfast programmes on children and adolescents: a systematic review2018Report (Other academic)
    Abstract [en]

    Background: Breakfast is often described as the most important meal of the day. The regularity of wholesome, daily meal patterns comprised of healthy foods is important for the physical and mental development of children and adolescents. One way to make sure that children and adolescents eat breakfast on a regular basis is to serve it at school. Several published reviews have examined the effects of eating breakfast and studied effects of school breakfast programmes on children and adolescents. Informed decisions of whether to promote eating breakfast or to introduce a school breakfast programme require a broader perspective.

    The aim was to conduct a systematic review of scientific publications that study the effects potentially relevant for economic evaluations of eating breakfast or implementing school breakfast programmes for children and adolescents.

    Method: In the systematic literature review, studies were identified by searching the electronic databases PubMed, CINAHL, Web of Science and PsycINFO from January 2000 through October 2017. The following inclusion criteria guided the selection of the identified studies: published articles from peer-reviewed journals with full text in English, studies collecting primary data, quantitative studies, studies performed in countries comparable to Sweden in terms of access and quality of nutrients, economic and social conditions and publications studying at least one of the topics; academic achievement, quality of life and wellbeing, risk factors/morbidity or cognitive performance.

    Results: Twenty-six studies on eating breakfast and eleven studies on school breakfast programmes fulfilled the inclusion criteria and were judged to be of at least moderate quality were included in the analysis. The results of the review of studies on eating breakfast showed positive and conclusive effects on cognitive performance, academic achievement, quality of life, well-being and risk factors/morbidity. This indicates that eating breakfast is important. The results of the studies on school breakfast varied. Minor positive effects were seen on cognitive performance and academic achievement. Most studies showed no effects and all studies suffered from different methodological weaknesses.

    Conclusions: The overall assessment of the studies on eating breakfast indicated positive effects. The studies on school breakfast programmes showed minor positive effects, but the majority of the studies showed no effects and all studies suffered from different methodological weaknesses. In order to assess the cost-effectiveness of eating breakfast and of school breakfast programmes we need to know more about how the identified affects influence the societal cost and the individuals gain in quality-adjusted life years both in the short and the long term.

  • 6.
    Lundqvist, Martina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Levin, Lars-Åke
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Roback, Kerstin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    The impact of service and hearing dogs on health-related quality of life and activity level: a Swedish longitudinal intervention study2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 497Article in journal (Refereed)
    Abstract [en]

    Background: Individuals with severe disability often require personal assistance and help from informal caregivers, in addition to conventional health care. The utilization of assistance dogs may decrease the need for health and social care and increase the independence of these individuals. Service and hearing dogs are trained to assist specific individuals and can be specialized to meet individual needs. The aim of this study was to describe and explore potential consequences for health-related quality of life, well-being and activity level, of having a certified service or hearing dog. Methods: A longitudinal interventional study with a pre-post design was conducted. At inclusion, all participants in the study had a regular (untrained) companion dog. Data were collected before training of the dog started and three months after certification of the dog. Health-related quality of life was assessed with EQ-5D-3L, EQ-VAS and RAND-36. Well-being was measured with WHO-5 and self-esteem with the Rosenberg Self-Esteem Scale. In addition, questions were asked about physical activity and time spent away from home and on social activities. Subgroups were analyzed for physical service and diabetes alert dogs. Results: Fifty-five owner-and-dog pairs completed the study (30 physical service dogs, 20 diabetes alert dogs, 2 epilepsy alert dogs, and 3 hearing dogs). Initially, study participants reported low health-related quality of life compared with the general population. At follow-up, health-related quality of life measured with the EQ-VAS, well-being and level of physical activity had improved significantly. In the subgroup analysis, physical service dog owners had lower health-related quality of life than diabetes alert dog owners. The improvement from baseline to follow-up measured with EQ-5D statistically differed between the subgroups. Conclusions: The target population for service and hearing dogs has an overall low health-related quality of life. Our study indicates that having a certified service or hearing dog may have positive impact on health-related quality of life, well-being and activity level. Service and hearing dogs are a potentially important "wagging tail aid" for this vulnerable population, able to alleviate strain, increase independence, and decrease the risk of social isolation.

  • 7.
    Roback, Kerstin
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Bernfort, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Allergy Center.
    Lundqvist, Martina
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Ordnad utmönstring av hälso- och sjukvårdsmetoder2016Report (Other academic)
    Abstract [en]

    Background

    It is a great challenge to provide a sustainable health care that maintain high quality and is available on equal terms for all citizens.

    Disinvestment in health care implies that existing health care services/interventions are removed from the publicly funded supply of health care or that they will be restricted in use. Quality improvements are continuously performed and unnecessary, harmful or ineffective services are replaced with new and better ones. This is generally not perceived as disinvestment. With time, however, a situation arises where it will be difficult to find "unnecessary, harmful or ineffective" care. This implies that clear priorities must be set for the provision of care and that evidence based disinvestment will be a necessary component to ensure the quality of care within limited budgets.

    The aim of this report on evidence based disinvestment is to describe how this is perceived and performed in Sweden's county councils and regions. We also give a brief overview of international disinvestment initiatives. The concept of disinvestment is illustrated by a number of ongoing or completed disinvestment initiatives and through a tentative framework for disinvestment in a Swedish context. The work has four parts:

    • An interview study for mapping disinvestment activities in Sweden
    • Case studies of active disinvestment
    • An overview of disinvestment initiatives internationally
    • A description of disinvestment processes and different types of disinvestment in a schematic framework

    Methods

    An initial literature search was performed in 2012 as a basis for a minor pilot study and to provide an introduction to the subject. The literature search was supplemented with new search terms in 2013 and 2015. The interviews were conducted by telephone with experts at Sweden's county councils and regions. A questionnaire was constructed to be used as an interview template and to serve as an e-mail survey in case any of our informants preferred this.

    Results

    In Sweden, open discussions on disinvestment of health care practices began in the early 2000s, which led to several counties starting to sketch on disinvestment policies. Few policies were, however, realized in practice. Organized disinvestment occurs in some counties/regions in the context of more general improvement or prioritization efforts and the term disinvestment is not always used. The majority of our respondents still thought that disinvestment was a significant issue requiring special attention.

    An evidence based disinvestment is always active, that is, it includes a conscious decision to stop using, restrict the use of, or withdraw resources from existing healthcare practices. The disinvestment work, however, was in most cases not clearly organized. The most active disinvestment work occurs where there is a priority setting committee or a group for evidence based adoption and disinvestment.

    This report describes disinvestment components and sub-processes in a schematic framework. The character of these processes was in large mapped by the interviews. Interview results were then synthesized with information from the literature into a tentative description of evidence based disinvestment. Whatever the causes and goals with disinvestment, the same problems arise and the work follows in large the same steps or sub-processes. Broadly, these sub-processes are:

    • identification of disinvestment objects
    • choice and preparation/assessment of disinvestment proposals
    • decision making
    • implementation of decisions and
    • follow-up and possible revision of decided disinvestments

    One of the sub-processes, that so far received little attention in Sweden, is how disinvestment decisions are implemented in operational health care. We have chosen to develop this in the framework as it seems to be an area on the rise internationally. There is a range of strategies and practical measures to facilitate and accelerate a desired change. This has been thoroughly investigated regarding implementation of new methods. Such strategies are based on different mechanisms to eliminate barriers and utilize facilitators.

    To illustrate the results presented in the report we present four cases of disinvestment in a little more detail. These are examples of how practices are identified as disinvestment objects, the preparation of cases, implementation of decisions, and of controversies that might arise. The cases have been selected to show the variation in types of disinvestment objects and the outcomes of disinvestment initiatives.

    Disinvestment has gained increased interest internationally in recent years. The problem of rising health care costs is present everywhere in the world and disinvestment is discussed in many countries. Early on, the focus was on disinvestment for greater efficiency. Then the trend turned to re-assessment of old services to be able to make evidence-based disinvestments. This resulted in so-called "low-value-lists" and "do-notdo" recommendations. Today, the focus is on measurable outputs of different disinvestment initiatives and studies have shown that compliance with "low-value-lists" is modest.

    Conclusions

    There are many indications that the future will call for efficient disinvestment processes to obtain a sustainable health care financing. Our study shows that disinvestment is used both for efficiency reasons and for cost control.

    • Most counties/regions are using or have used disinvestment; defined as decisions to withdraw or restrict the use of services/interventions in publicly funded health care.
    • The main reasons for disinvestment is the need for: quality improvements, reallocation of resources to new practices, cost control and/or better efficiency.
    • We identified two main types of organized disinvestment in Sweden: -  evidence based adoption including disinvestment as an integral part, and - proactive identification of disinvestment objects with a subsequent assessment and prioritization of the objects.
    • Services that are withdrawn or restricted in use is a mixture of pharmaceuticals, non-pharmaceutical methods and organizational arrangements.
    • Many withdrawn services remains available as privately funded options.
    • Prioritization principles are often indicative of disinvestment work and evidence-based medicine and health technology assessment are considered as obvious components.
    • Important criteria for classification as disinvestment candidates are: - the service/intervention has adverse effects or very little clinical benefit - the service/intervention is not cost effective - the service/intervention is perceived to have negative effects on the organization and/or work environment
    • There are also services that have been removed due to ethical considerations on what publicly funded healthcare should cover.
    • Today, disinvestment takes place without sufficient openness and citizen involvement in the processes. Documentation of the work, to the extent there is any, is usually not readily accessible.

    In order to improve health care quality, and at the same time control rising costs, it will be required that disinvestment is placed on the national agenda. Ethically difficult considerations associated with disinvestment have made it a question hard to tackle for decision makers at the regional political and administrative levels. Conflicting interests may arise between the patient and the caregiver's budgetary commitment. It is not always easy to determine which interventions are medically and socially justified in the individual patient case, which induces ethical dilemmas.

    Regardless of the ethical dilemmas and difficulties that arise – and at which organizational level decisions are made – a useful working model will be required for active withdrawal of services from the supply of publicly funded health care. In our study, we have outlined a framework that describes the processes, including medical and economic as well as social and ethical aspects.

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