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  • 1. Ameh, Soter
    et al.
    Klipstein-Grobusch, Kerstin
    D'ambruoso, Lucia
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana.
    Gomez-Olive, Francesc Xavier
    Quality of integrated chronic disease care in rural South Africa: user and provider perspectives2017In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, no 2, p. 257-266Article in journal (Refereed)
    Abstract [en]

    The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients >= 18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian's structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low-and middle-income countries.

  • 2.
    Andersén, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Bäckström, Torbjörn
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Dahlquist, Gisela
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Damber, Jan-Erik
    Engström-Laurent, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Hjemdahl, Paul
    Korsgren, Olle
    Olsson, Håkan
    Wiberg, Mikael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Hand Surgery.
    Widmark, Anders
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    Svensk medicinsk forskning behöver inte mer styrning2014In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 111, no 22-23, p. 980-981Article in journal (Other (popular science, discussion, etc.))
  • 3.
    Anh Huyen, Nguyen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Provider Payment Methods of healthcare service in Vietnam: a literature review2015Independent thesis Advanced level (degree of Master (One Year)), 10 credits / 15 HE creditsStudent thesis
    Abstract [en]

    Background

     Achieving access to basic health care for the entire population without risk of catastrophic expenditure and impoverishment is an important goal for Vietnam’s health system. Provider payment methods (PPM), which is an important component of purchasing and health financing, are powerful tools to promote the health system and achieve health policy objectives. However, the current PPM in Vietnam appears have drawbacks in both framework and arrangement. Reforms  of PPM and the health financing system are required.

    Objective

     The objective of this study is to identify the PPM mechanism in the health financing system of Vietnam, in order to provide scientific evidences for the reform process.

    Methods

     A literature review using the search terms “Vietnam “, “provider payment method”, “purchasing” and “health financing” is carried out in different databases:  Pubmed, Google Scholar, Science Direct, World Health Organization (WHO) and Word Bank (WB) library. The reference lists of included studies are also screeedn in the selecting process. Studies are included following criteria 1. Published from 1995 to March of 2015 2. Written in English and 3. Report, analyze PPM evolved in health financing system. Not only articles and papers, reports and books are also included to be reviewed.

    Results

      Among 78 papers, reports and books primarily, only 10 studies are eligible with 4 studies conducting assessment and 6 studies being reviews. About the structure of PPM, Vietnam operates a mixed system which consists of global budget, line item, fee-for-services (FFS)  and capitation.  FFS play the biggest role in the system but also receive the most critical assessments. Capitation, which has evolved since 2005, is far from the success found in other coountries. There are 2 purchaser contributed in system, Vietnam social security (VSS) and Ministry of health (MOH).  The suggestion for developing the mix of system of capitation and fee for services or transforming FFS to the capitation and case-based payment system are discussed.

    Conclusion

      There is a limited number of PPM in Vietnam and it is necessary to implement more empirical studies such as pilot study for different new scenarios of mixing PPM  as well as evaluation studies to find the best reform process in the future. 

  • 4. Appelros, Peter
    et al.
    Stegmayr, Birgitta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Terént, Andreas
    Riks-Stroke och hur fallgropar vid tolkning av resultaten undviks2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 8, p. 529-533Article in journal (Other academic)
  • 5. Arne, Mats
    et al.
    Emtner, Margareta
    Lisspers, Karin
    Wadell, Karin
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Stallberg, Bjorn
    Availability of pulmonary rehabilitation in primary care for patients with COPD: a cross-sectional study in Sweden2016In: EUROPEAN CLINICAL RESPIRATORY JOURNAL, ISSN 2001-8525, Vol. 3, article id 31601Article in journal (Refereed)
    Abstract [en]

    Background: Pulmonary rehabilitation (PR) is an important, evidence-based component for the management of individuals with chronic obstructive pulmonary disease (COPD). In daily practice, the majority of COPD patients are treated in primary care. However, information about the availability of PR in primary care in Sweden is lacking. The aim was to investigate the availability of rehabilitation resources in primary care settings for patients with COPD in Sweden. Methods: A cross-sectional descriptive design was applied, using web-based questionnaires sent to all primary care centres in four regions, comprising more than half of the 9.6 million inhabitants of Sweden. The main questionnaire included questions about the content and availability of rehabilitation resources for COPD patients. PR was defined as exercise training and one or more of the following activities: education, nutritional intervention, energy conservation techniques or psychosocial support. Results: A total of 381 (55.9%) of the 682 primary care centres answered the main questionnaire. In addition to physicians and nurses, availability of healthcare professionals for rehabilitation in primary care settings was physiotherapists 92.0%, occupational therapists 91.9%, dieticians 83.9% and social workers or psychologists 98.4%. At 23.7% of all centres, PRwas not available toCOPD patients - neither in primary care nor at hospitals. Conclusion: Despite high availability of professionals for rehabilitation in primary care settings, about one-quarter of managers at primary care centres stated that their COPD patients had no access to PR. This indicates a need to structure resources for rehabilitation and to present and communicate the available resources within the healthcare system.

  • 6.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hermerén, Göran
    The need to revise the Helsinki Declaration2017In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 389, no 10075, p. 1190-1191Article in journal (Refereed)
  • 7. Backhans, Mona Christina
    et al.
    Burström, Bo
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Månsdotter, Anna
    Pioneers and laggards: Is the effect of gender equality on health dependent on context?2009In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 68, p. 1388-1395Article in journal (Refereed)
    Abstract [en]

    This study combines data at individual and area level to examine interactions between equality within couples and gender equality in the municipality in which individuals live. The research question is whether the context impacts on the association between gender equality and health. The material consists of data on 37,423 men and 37,616 women in 279 Swedish municipalities, who had their first child in 1978. The couples were classified according to indicators of their level of gender equality in 1980 in the public sphere (occupation and income) and private sphere (child care leave and parental leave) compared to that of their municipality. The health outcome is compensated days from sickness insurance during 1986-1999 with a cut-off at the 85% percentile. Data were analysed using logistic regression with the overall odds as reference. The results concerning gender equality in the private sphere show that among fathers, those who are equal in an equal municipality have lower levels of sick leave than the average while laggards (less equal than their municipality) and modest laggards have higher levels. In the public sphere, pioneers (more equal t han their municipality) fare better than the average while laggards fare worse. For mothers, those who are traditional in their roles in the public sphere are protected from high levels of sick leave, while the reverse is true for those who are equal. Traditional mothers in a traditional municipality have the lowest level of sick leave and pioneers the highest. These results show that there are distinct benefits as well as disadvantages to being a gender pioneer and/or a laggard in comparison to your municipality. The associations are markedly different for men and women.

  • 8.
    Backman, Annica
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sjögren, Karin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lövheim, Hugo
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Edvardsson, David
    Umeå University, Faculty of Medicine, Department of Nursing. School of Nursing and Midwifer y, La Trobe University, Melbourne, VIC, Australia.
    Towards person-centredness in aged-care: exploring the impact of leadership2016In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 24, no 6, p. 766-774Article in journal (Refereed)
    Abstract [en]

    Aim: To explore the association between leadership behaviours among managers in aged care, and person‐centredness of care and the psychosocial climate.

    Background: Theory suggests that leadership is important for improving person‐centredness in aged care, however, empirical evidence is lacking.

    Methods: A cross‐sectional design was used to collect data from Swedish aged care staff (= 3661). Valid and reliable questionnaires assessing leadership behaviours, person‐centeredness of care and the psychosocial climate were used. Data were analysed using multiple linear regression including interaction terms.

    Results: Leadership behaviours were significantly related to the person‐centredness of care and the psychosocial climate. The level of person‐centredness of care moderated the impact of leadership on the psychosocial climate.

    Conclusions and implications for nursing management: The leadership behaviour of managers significantly impacts person‐centred care practice and contributes to the psychosocial climate for both staff and residents in aged care. This study is the first empirically to confirm that middle managers have a central leadership role in developing and supporting person‐centred care practice, thereby creating a positive psychosocial climate and high quality care.

  • 9.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Assessing the dimensionality of YFHS-Swe: a questionnaire to assess youth-friendliness in differentiated health services2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1380399Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to assess the dimensionality of YFHS-Swe and identify possible unique factors in the evaluation of youth-friendliness. YFHS-Swe was answered by 1110 youths aged 16 to 25 years visiting youth clinics in Northern Sweden. Thirteen factors were identified by exploratory factor analysis and except for one factor they all proved to fit well and have good reliability when assessed by the confirmatory factor analysis. The YFHS-Swe proved to be credible and suitable for assessing youth-friendliness of differentiated health services in Sweden. With cultural and linguistic adaptations, it can be used in similar settings internationally.

  • 10.
    Bejerholm, Ulrika
    et al.
    Lunds universitet, Institutionen för hälsovetenskaper.
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bergmark, Magnus
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Svensson, Bengt
    Lunds universitet, Institutionen för hälsovetenskaper.
    From national incentives of implementing Individual Placement and Support to the impact on the service users' quality of life, and view on support2015In: Closing the gap between research and policy in mental health: ENMESH 2015 : Eleventh International Conference of the European Network For Mental Health Service Research : Book of Abstracts, ENMESH , 2015Conference paper (Refereed)
  • 11. Bennett, Sara
    et al.
    Mahmood, Shehrin Shaila
    Edward, Anbrasi
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Ekirapa-Kiracho, Elizabeth
    Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda2017In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, article id 108Article in journal (Refereed)
    Abstract [en]

    Background: Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.

    Methods: We draw upon three IR studies conducted by Future Health Systems (FHS) in Afghanistan, Bangladesh and Uganda. We reviewed project documents from the period 2011-2016 to identify information related, to the dimensions of scaling up. Further, for each country, we developed rich descriptions of how the research teams approached scaling up, and how IR contributed to scale-up. The rich descriptions were checked by FHS research teams. We identified common patterns and. differences across the three cases.

    Results: The three cases planned quite different innovations/interventions and had very different types of scale-up strategies. In all three cases, the research teams had extensive prior experience within the study communities, and. little explicit attention was paid, to contextual factors. All three cases involved complex interactions between the research teams and other stakeholders, among stakeholders, and between stakeholders and the intervention. The IR planned by the research teams focussed primarily on feasibility and effectiveness, but in practice, the research teams also had critical insights into other factors such as sustainability, acceptability, cost-effectiveness and appropriateness. Stakeholder analyses and other project management tools further complemented IR.

    Conclusions: IR can provide significant insights into how best to scale-up a particular intervention. To take advantage of insights from IR, scale-up strategies require flexibility and IR must also be sufficiently flexible to respond to new emerging questions. While commonly used conceptual frameworks for scale-up clearly delineate actors, such as implementers, target communities and the support team, in our experience, IR blurred the links between these groups.

  • 12.
    Bergman, Mats A.
    et al.
    Södertörns Högskola.
    Johansson, Per
    Uppsala University.
    Lundberg, Sofia
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Economics.
    Spagnolo, Giancarlo
    Stockholm School of Economics.
    Privatization and quality: evidence from elderly care in Sweden2016In: Journal of Health Economics, ISSN 0167-6296, E-ISSN 1879-1646, Vol. 49, p. 109-119Article in journal (Refereed)
    Abstract [en]

    Non-contractible quality dimensions are at risk of degradation when the provision of public services is privatized. However, privatization may increase quality by fostering performance-improving innovation, particularly if combined with increased competition. We assemble a large data set on elderly care services in Sweden between 1990 and 2009 and estimate how opening to private provision affected mortality rates – an important and not easily contractible quality dimension – using a difference-in-difference-in-difference approach. The results indicate that privatization and the associated increase in competition significantly improved non-contractible quality as measured by mortality rates. 

  • 13. Bergman, Mats
    et al.
    Granlund, David
    Umeå University, Faculty of Social Sciences, Department of Economics.
    Rudholm, Niklas
    Reforming the Swedish pharmaceuticals market: consequences for costs per defined daily dose2016In: International Journal of Health Economics and Management, ISSN 2199-9023, E-ISSN 2199-9031, Vol. 16, no 3, p. 201-214Article in journal (Refereed)
    Abstract [en]

    In 2009 and 2010, the Swedish pharmaceuticals market was reformed. One of the stated policy goals was to achieve low costs for pharmaceutical products dispensed in Sweden. We use price and sales data for off-patent brand-name and generic pharmaceuticals to estimate a log-linear regression model, allowing us to assess how the policy changes affected the cost per defined daily dose. The estimated effect is an 18 % cost reduction per defined daily dose at the retail level and a 34 % reduction in the prices at the wholesale level (pharmacies’ purchase prices). The empirical results suggest that the cost reductions were caused by the introduction of a price cap, an obligation to dispense the lowest-cost generic substitute available in the whole Swedish market, and the introduction of well-defined exchange groups. The reforms thus reduced the cost per defined daily dose for consumers while being advantageous also for the pharmacies, who saw their retail margins increase. However, pharmaceutical firms supplying off-patent pharmaceuticals experienced a clear reduction in the price received for their products.

  • 14.
    Bergmark, Magnus
    et al.
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Bejerholm, Ulrika
    Lunds universitet, Institutionen för hälsovetenskaper..
    Markström, Urban
    Umeå University, Faculty of Social Sciences, Department of Social Work.
    Policy Changes in Community Mental Health: Interventions and Strategies Used in Sweden over 20 Years2017In: Social Policy & Administration, ISSN 0144-5596, E-ISSN 1467-9515, Vol. 51, no 1, p. 95-113Article in journal (Refereed)
    Abstract [en]

    The deinstitutionalization of mental health care has changed the responsibilities of involved authoritiesand has led to a continuous need for new treatment forms and interventions. This articledescribes this development in Europe, and in particular how these new conditions have been handledin Sweden over the past 20 years at the level of governmental policy-making. Three major policydocuments from 1994, 2009 and 2012 were included in this study. To increase our understandingof the policies’ contents, we have used theoretical concepts concerning governance,implementation and political risk management. Although our main interest was to find out howthe government handles interventions for users of the mental health care system, we found that thepolicy work is progressing stepwise. The first document, from the deinstitutionalization era, did notdiscuss interventions clearly. Instead, it was mainly concerned with both practical and economicalareas of responsibility. The second document, from the post-deinstitutionalization era, was morefocused on what services should be delivered to the users, while the most recently published documentto a greater extent addressed the question of how the support is supposed to be designed. The trendin European community mental health policy has been to advocate services in open forms that areintegrated into the society’s other care systems. This is also the case in Sweden, and continuous workis being done by the government to find strategies to support the development, and to meet the needs atboth political and local levels.

  • 15. Björk, Anna Bell
    et al.
    Hillborg, Helene
    Augutis, Marika
    Umefjord, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Evolving techniques in text-based medical consultation: Physicians' long-term experiences at an Ask the doctor service2017In: International Journal of Medical Informatics, ISSN 1386-5056, E-ISSN 1872-8243, Vol. 105, p. 83-88Article in journal (Refereed)
    Abstract [en]

    Introduction: Both the demands and the options for patients to communicate with health care providers utilizing eHealth solutions are increasing. Some patients, or relatives to patients, want to consult another health care provider than the regular one, merely in text.

    Objective: To improve text-based medical consultation by learning from long-term experiences.

    Materials and methods: Physicians with comprehensive experience of answering free-text medical inquiries at an official health portal in Sweden were interviewed. The interviews were analyzed using a grounded theory approach.

    Results: Over time, the interviewed physicians developed strategies on how to formulate the answer to a medical inquiry from a previously unknown inquirer. The answering physicians experienced their primary role as providers of medical information and as mediators between an inquirer and the regular health care provider. Many of the answering physicians experienced a personal development with improved communication skills, also in face-to-face meetings with patients.

    Conclusion: Text-based medical consultation is part of an expanding area in eHealth. The development of strategies, guidelines, ethical considerations as well as educational efforts are needed to optimize the skills of asynchronous text-based health consultation.

  • 16.
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Medicin–geriatrik-kliniken, Skellefteå lasarett.
    Hög dödlighet bland hjärtinfarktpatienter som inte vårdats på HIA: fördjupad analys nödvändig2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 17-18, p. 1270-1271Article in journal (Other academic)
  • 17.
    Brändström, Helge
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Haney, Michael
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Regional intensive care transports: a prospective analysis of distance, time and cost for road, helicopter and fixed-wing ambulances2014In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 22, p. 36-Article in journal (Refereed)
    Abstract [en]

    Background: There are three different types of ambulance systems, all of which can manage the same secondary intensive care patient transport mission: road ambulance, rotor-wing ambulance, and fixed-wing ambulance. We hypothesized that costs for specific transport distances would differ between systems. We aimed to analyze distances and observed times for ambulance intensive care secondary transport missions together with system costs to assess this. Methods: We prospectively collected data for consecutive urgent intensive care transports into the regional tertiary care hospital in the northern region of Sweden. Distances and transport times were gathered, and a cost model was generated based on these together with fixed and operating costs from the three different ambulance systems. Distance-cost and time-cost estimations were then generated for each transport system. Results: Road ambulance cost relatively less for shorter distances (within 250 kilometers/155 miles) but were relatively time ineffective. The rotor-wing systems were most expensive regardless of distance; but were most time-effective up to 400-500 km (248-310 miles). Fixed-wing systems were more cost-effective for longer distance (300 km/186 miles), and time effective for transports over 500 km (310 miles). Conclusions: In summary, based on an economic model developed from observed regional ICU patient transports, and cost estimations, different ambulance system cost-distances could be compared. Distance-cost and time results show that helicopters can be effective up to moderate ICU transport distances (400-500), though are expensive to operate. For longer ICU patient transports, fixed-wing transport systems are both cost and time effective compared to helicopter-based systems.

  • 18.
    Brännström, Margareta
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Fürst, Carl Johan
    Tishelman, Carol
    Petzold, Max
    Lindqvist, Olav
    Umeå University, Faculty of Medicine, Department of Nursing. Medical Management Centre (MMC), Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Effectiveness of the Liverpool care pathway for the dying in residential care homes: An exploratory, controlled before-and-after study2016In: Palliative Medicine: A Multiprofessional Journal, ISSN 0269-2163, E-ISSN 1477-030X, Vol. 30, no 1, p. 54-63Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Clinical pathways aim to ensure that individuals receive appropriate evidence-based care and interventions, with the Liverpool Care Pathway for the Dying Patient focusing on end of life. However, controlled studies of the Liverpool Care Pathway for the Dying Patient, particularly outside of cancer settings, are lacking.

    AIM: To compare the effects of the Liverpool Care Pathway for the Dying Patient and usual care on patients' symptom distress and well-being during the last days of life, in residential care homes.

    DESIGN: Exploratory, controlled before-and-after study. During a 15-month baseline, usual care was carried out in two areas. During the following 15-months, usual care continued in the control area, while residential care home staff implemented Liverpool Care Pathway for the Dying Patient use in the intervention area. The intervention was evaluated by family members completing retrospective symptom assessments after the patient's death, using the Edmonton Symptom Assessment System and Views of Informal Carers - Evaluation of Services.

    SETTINGS/PARTICIPANTS: Patients who died at all 19 residential care homes in one municipality in Sweden.

    RESULTS: Shortness of breath (estimate = -2.46; 95% confidence interval = -4.43 to -0.49) and nausea (estimate = -1.83; 95% confidence interval = -3.12 to -0.54) were significantly reduced in Edmonton Symptom Assessment System in patients in the intervention compared to the control area. A statistically significant improvement in shortness of breath was also found on the Views of Informal Carers - Evaluation of Services item (estimate = -0.47; 95% confidence interval = -0.85 to -0.08).

    CONCLUSION: When implemented with adequate staff training and support, the Liverpool Care Pathway for the Dying Patient may be a useful tool for providing end-of-life care of elderly people at the end of life in non-cancer settings.

  • 19. Burman, Matthew
    et al.
    Nikolayenskyy, Vladyslav
    Kontsevaya, Irina
    Molina-Moya, Barbara
    Rzhepishevska, Olena
    Umeå University, Faculty of Science and Technology, Department of Chemistry.
    Guglielmetti, Lorenzo
    Tackling the MDR-TB epidemic in Ukraine: every little helps … and much more needed2017In: Journal of Public Health, ISSN 2198-1833, E-ISSN 1613-2238Article in journal (Refereed)
  • 20. By, Asa
    et al.
    Sobocki, Patrik
    Forsgren, Arne
    Silfverdal, Sven-Arne
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Comparing health outcomes and costs of general vaccination with pneumococcal conjugate vaccines in sweden: a markov model.2012In: Clinical Therapeutics, ISSN 0149-2918, E-ISSN 1879-114X, Vol. 34, no 1, p. 177-89Article in journal (Refereed)
    Abstract [en]

    Background: Two new pneumococcal conjugate vaccines were licensed to immunize infants and young children against pneumococcal disease.

    Objectives: The objective of this study was to estimate the expected health benefits, costs, and incremental cost-effectiveness of routine vaccination with the 10-valent pneumococcal nontypeable hemophilus influenza protein-D conjugate vaccine (PHiD-CV) compared with the 13-valent pneumococcal conjugate vaccine (PCV13) in Sweden.

    Methods: A Markov cohort model was used to estimate the effect of vaccination at vaccine steady state, taking a societal perspective and using a 2+1 vaccination schedule. Price parity was assumed between the vaccines. Outcomes were measured by reduction in disease burden, costs, quality-adjusted life–years (QALYs) and incremental cost-effectiveness ratio.

    Results: The results predicted that PCV13 would prevent 3 additional cases of invasive pneumococcal disease and 34 additional cases of pneumonia, whereas PHiD-CV would avoid 3 additional cases of mastoiditis, 1010 tube insertions, and 10,420 cases of ambulatory acute otitis media compared with PCV13. By combining morbidity and mortality benefits of all clinical outcomes, PHiD-CV would generate 45.3 additional QALYs compared with PCV13 and generate savings of an estimated 62 million Swedish kronors.

    Conclusion: The present study predicted lower costs and better health outcome (QALYs) gained by introducing PHiD-CV compared with PCV13 in routine vaccination. Our results indicated that PHiD-CV is cost-effective compared with PCV13 in Sweden.

  • 21. Byskov, Jens
    et al.
    Maluka, Stephen Oswald
    Marchal, Bruno
    Shayo, Elizabeth H.
    Bukachi, Salome
    Zulu, Joseph M.
    Blas, Erik
    Michelo, Charles
    Ndawi, Benedict
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The Need for Global Application of the Accountability for Reasonableness Approach to Support Sustainable Outcomes Comment on "Expanded HTA Enhancing Fairness and Legitimacy"2017In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 6, no 2, p. 115-118Article in journal (Refereed)
    Abstract [en]

    The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. This has again influenced the development of the concept, but not led to universal application. The potential use in health technology assessments (HTAs) has recently been identified by Daniels et al as yet another excellent justification for AFR-based process guidance that refers to both qualitative and a broader participatory input for HTA, but it has raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions and the through these repeatedly documented motivation for their consolidation, we argue that it can even be unethical not to take AFR conditions beyond their still mainly formative stage and test their application within routine health systems management for their expected support to more sustainable health improvements. The ever increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. Legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and indeed differences in evidence to arrive at a by all understood, accepted, but not necessarily agreed compromise in a current context -until major premises for the decision change. AFR should be widely adopted in projects and services under close monitoring and frequent reviews.

  • 22.
    Bölenius, Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Brulin, Christine
    Umeå University, Faculty of Medicine, Department of Nursing.
    Grankvist, Kjell
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Nilsson, Karin
    Umeå University, Faculty of Medicine, Department of Nursing. Institutionen för omvårdnad i Örnsköldsvik.
    Söderberg, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Impact of a large-scale educational intervention program on venous blood specimen collection practices2013In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, article id 463Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Phlebotomy performed with poor adherence to venous blood specimen collection (VBSC) guidelines jeopardizes patient safety and may lead to patient suffering and adverse events. A first questionnaire study demonstrated low compliance to VBSC guidelines, motivating an educational intervention of all phlebotomists within a county council. The aim was to evaluate the impact of a large-scale educational intervention program (EIP) on primary health care phlebotomists' adherence to VBSC guidelines. We hypothesised that the EIP would improve phlebotomists' VBSC practical performance.

    METHODS: The present study comprise primary health care centres (n = 61) from two county councils in northern Sweden. The final selected study group consisted of phlebotomists divided into an intervention group (n = 84) and a corresponding control group (n = 79). Both groups responded to a validated self-reported VBSC questionnaire twice. The EIP included three parts: guideline studies, an oral presentation, and an examination. Non-parametric statistics were used for comparison within and between the groups.

    RESULTS: Evaluating the EIP, we found significant improvements in the intervention group compared to the control group on self-reported questionnaire responses regarding information search (ES = 0.23-0.33, p < 0.001-0.003), and patient rest prior to phlebotomy (ES = 0.27, p = 0.004). Test request management, patient identity control, release of venous stasis, and test tube labelling had significantly improved in the intervention group but did not significantly differ from the control group (ES = 0.22- 0.49, p = < 0.001- 0.006). The control group showed no significant improvements at all (ES = 0--0.39, p = 0.016-0.961).

    CONCLUSIONS: The present study demonstrated several significant improvements on phlebotomists' adherence to VBSC practices. Still, guideline adherence improvement to several crucial phlebotomy practices is needed. We cannot conclude that the improvements are solely due to the EIP and suggest future efforts to improve VBSC. The program should provide time for reflections and discussions. Furthermore, a modular structure would allow directed educational intervention based on the specific VBSC guideline flaws existing at a specific unit. Such an approach is probably more effective at improving and sustaining adherence to VBSC guidelines than an EIP containing general pre-analytical practices.

  • 23.
    Carson, Dean B.
    et al.
    Umeå University, Arctic Research Centre at Umeå University. Northern Institute, Charles Darwin University, Darwin, Australia; Glesbygdsmedicinskt Centrum, Storuman, Sweden .
    Schoo, Adrian
    Berggren, Peter
    The 'rural pipeline' and retention of rural health professionals in Europe's northern peripheries2015In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 119, no 12, p. 1550-1556Article in journal (Refereed)
    Abstract [en]

    The major advance in informing rural workforce policy internationally over the past 25 years has been the recognition of the importance of the 'rural pipeline'. The rural pipeline suggests that people with 'rural origin' (who spent some childhood years in rural areas) and/or 'rural exposure' (who do part of their professional training in rural areas) are more likely to select rural work locations. What is not known is whether the rural pipeline also increases the length of time professionals spend in rural practice throughout their careers. This paper analyses data from a survey of rural health professionals in six countries in the northern periphery of Europe in 2013 to examine the relationship between rural origin and rural exposure and the intention to remain in the current rural job or to preference rural jobs in future. Results are compared between countries, between different types of rural areas (based on accessibility to urban centres), different occupations and workers at different stages of their careers. The research concludes that overall the pipeline does impact on retention, and that both rural origin and rural exposure make a contribution. However, the relationship is not strong in all contexts, and health workforce policy should recognise that retention may in some cases be improved by recruiting beyond the pipeline.

  • 24. Chadda, S.
    et al.
    Larkin, M.
    Jones, C.
    Sykes, D.
    Barber, B.
    Zhao, Z.
    Gao, S.
    Bengtsson, Nils-Olof
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Oncology.
    The impact of infusion reactions associated with monoclonal antibodies in metastatic colorectal cancer: a european perspective2011In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 14, no 3, p. A173-A173Article in journal (Refereed)
  • 25.
    Dahlgren, K.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Holzmann, M. J.
    Carlsson, A. C.
    Wandelld, P.
    Hasselstrom, J.
    Ruge, Toralph
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    The use of a Swedish telephone medical advice service by the elderly: a population-based study2017In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 35, no 1, p. 98-104Article in journal (Refereed)
    Abstract [en]

    Objective: The present study aimed to describe contact made by the elderly to Sweden's nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres. Design: De-identified data from recorded calls to HGP was extracted for analysis (n=7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system.Setting: Vasterbotten County, Sweden.Subjects: Patients over 80 years.Main outcome measures: Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations. Results: The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r=0.30, p<0.05) and calls that were given advice correlated with acute primary healthcare visits (r=0.38, p=0.005). Conclusion: The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service's present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly's medication regimens.

  • 26.
    Dahlquist, Gisela
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Utvärdering av processekonomi ger otillräckligt underlag för vårdpolitiska beslut1995In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 92, no 21, p. 2211-Article in journal (Refereed)
  • 27.
    Dahlquist, Gisela
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Janson, Staffan
    Barn och ungdomar: sårbara »osynliga« anhöriga2013In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 110, no 45, p. 2003-Article in journal (Other (popular science, discussion, etc.))
  • 28.
    Dahlquist, Gisela
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Janson, Staffan
    Örebro universitet.
    Kräv vetenskaplig evidens för surrogatmoderskap2013In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 110, no 25-26, p. 1200-1201Article in journal (Other (popular science, discussion, etc.))
  • 29.
    Dahlquist, Gisela
    et al.
    Department of Pediatrics, Sachs' Children Hospital, Stockholm.
    Persson, B
    Wallensten, M
    Vem ska betala diabetesungdomars undervisning i egenvård?1989In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 86, no 45, p. 3884-Article in journal (Other (popular science, discussion, etc.))
  • 30. de Bruijn, Winnie
    et al.
    Ibanez, Cristina
    Frisk, Pia
    Pedersen, Hanne Bak
    Alkan, Ali
    Bonanno, Patricia Vella
    Brkicic, Ljiljana S.
    Bucsicsa, Anna
    Dedet, Guillaume
    Eriksen, Jaran
    Fadare, Joseph O.
    Furst, Jurij
    Gallego, Gisselle
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience. School of Medicine, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.
    Godoi, Isabella P.
    Guerra Junior, Augusto A.
    Gursoz, Hakki
    Jan, Saira
    Jones, Jan
    Joppi, Roberta
    Kerman, Saim
    Laius, Ott
    Madzikwa, Newman
    Magnusson, Einar
    Maticic, Mojca
    Markovic-Pekovic, Vanda
    Massele, Amos
    Ogunleye, Olayinka
    O'Leary, Aisling
    Piessnegger, Jutta
    Sermet, Catherine
    Simoens, Steven
    Tiroyakgosi, Celda
    Truter, Ilse
    Thyberg, Magnus
    Tomekova, Kristina
    Wladysiuk, Magdalena
    Vandoros, Sotiris
    Vural, Elif H.
    Zara, Corinne
    Godman, Brian
    Introduction and Utilization of High Priced HCV Medicines across Europe: Implications for the Future2016In: Frontiers in Pharmacology, ISSN 1663-9812, E-ISSN 1663-9812, Vol. 7, article id 197Article in journal (Refereed)
    Abstract [en]

    Background: Infection with the Hepatitis C Virus (HCV) is a widespread transmittable disease with a diagnosed prevalence of 2.0%. Fortunately, it is now curable in most patients. Sales of medicines to treat HCV infection grew 2.7% per year between 2004 and 2011, enhanced by the launch of the protease inhibitors (Hs) boceprevir (BCV) and telaprevir (TVR) in addition to ribavirin and pegylated interferon (pegIFN). Costs will continue to rise with new treatments including sofosbuvir, which now include interferon free regimens. Objective: Assess the uptake of BCV and TVR across Europe from a health authority perspective to offer future guidance on dealing with new high cost medicines. Methods: Cross-sectional descriptive study of medicines to treat HCV (pegIEN, ribavirin, BCV and TVR) among European countries from 2008 to 2013. Utilization measured in defined daily doses (DDDs)/1000 patients/quarter (DIOs) and expenditure in Euros/DDD. Health authority activities to influence treatments categorized using the 4E methodology (Education, Engineering, Economics and Enforcement). Results: Similar uptake of BCV and TVR among European countries and regions, ranging from 0.5 DIQ in Denmark, Netherlands and Slovenia to 1.5 DIQ in Tayside and Catalonia in 2013. However, different utilization of the new Pls vs. ribavirin indicates differences in dual vs. triple therapy, which is down to factors including physician preference and genotypes. Reimbursed prices for BCV and TVR were comparable across countries. Conclusion: There was reasonable consistency in the utilization of BCV and TVR among European countries in comparison with other high priced medicines. This may reflect the social demand to limit the transmission of HCV. However, the situation is changing with new curative medicines for HCV genotype 1 (GT1) with potentially an appreciable budget impact. These concerns have resulted in different prices across countries, with their impact on budgets and patient outcomes monitored in the future to provide additional guidance.

  • 31.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Ntaganira, Joseph
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali ,Rwanda.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study2016In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 21, no 7, p. 895-906Article in journal (Refereed)
    Abstract [en]

    Objective To explore Rwandan physicians' experiences and views on the role of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Methods Physicians (n=19) in public and private health facilities in urban and rural Rwanda were interviewed in 2015 as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed qualitatively. Results Ultrasound was described as an important tool in maternity care. Availability and quality of equipment varied across sites, and considerable disparities in obstetric ultrasound utilisation between rural and urban areas were described. The physicians wanted more ultrasound training and saw the potential for midwives to perform basic scans. Information about fetal sex and well-being was described as women's main expectations of ultrasound. Although women's right to autonomy in pregnancy was supported in principle by participating physicians, fetal rights were sometimes seen as needing physician protection'. Conclusions There appears to be increasing use and demand for obstetric ultrasound in Rwanda, particularly in urban areas. It seems important to monitor this development closely to secure wise and fair allocation of scarce obstetric expertise and resources and to prevent overuse or misuse of ultrasound. Raising awareness about the benefits of all aspects of antenatal care, including ultrasound may be an important step to improve pregnant women's uptake of services. Increased opportunities for formal ultrasound training, including the training of midwives to perform basic scans, seem warranted. Moreover, in parallel with the transition to more medico-technical maternity care, a dialogue about maternal rights to autonomy in pregnancy and childbirth is imperative.

  • 32.
    Ekblom, Kim
    et al.
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry. Department of Clinical Chemistry and Transfusion Medicine, Växjö Central Hospital, Växjö, Sweden.
    Petersson, Annika
    Introduction of Cost Display Reduces Laboratory Test Utilization2018In: American Journal of Managed Care, ISSN 1088-0224, E-ISSN 1936-2692, Vol. 24, no 5, p. E164-E169Article in journal (Refereed)
    Abstract [en]

    Objectives: To study the effects on the number of laboratory tests ordered after introduction of cost display (showing the cost in the computerized test ordering system at test ordering and test result delivery) and cost charge (requiring all primary healthcare centers to pay full laboratory costs of the ordered tests).

    Study design: The study included cost display for secondary healthcare centers (inpatient hospitals, emergency departments, and outpatient specialist providers) as well as publicly and privately operated primary healthcare centers (sites of nonemergency, nonspecialist healthcare). After 3 months cost charge was introduced by management for all primary healthcare centers.

    Methods: Information on laboratory test name in the test ordering system, resulting in cost display both at the moment of test ordering and at the presentation of the test result. Numbers of laboratory tests were obtained from the laboratory information system and calculated as tests per physician visit. Cost charge was managed through the established laboratory invoicing system.

    Results: In the publicly operated primary healthcare centers, neither if the interventions had any effect on laboratory test volume, nor did cost display have an effect in the privately operated primary healthcare centers. However, introduction of cost charge significantly decreased laboratory test ordering in the privately operated primary healthcare centers.In contrast, secondary healthcare centers lowered test volumes when cost display was introduced.

    Conclusions: The results support cost awareness and cost charge as means of reducing laboratory utilization. However, the outcome varies with the setting.

  • 33. Ekirapa-Kiracho, Elizabeth
    et al.
    Kananura, Rornald Muhumuza
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.
    Namazzi, Gertrude
    Mutebi, Aloysius
    George, Asha
    Paina, Ligia
    Waiswa, Peter
    Bumba, Ahmed
    Mulekwa, Godfrey
    Nakiganda-Busiku, Dinah
    Lyagoba, Moses
    Naiga, Harriet
    Putan, Mary
    Kulwenza, Agatha
    Ajeani, Judith
    Kakaire-Kirunda, Ayub
    Makumbi, Fred
    Atuyambe, Lynn
    Okui, Olico
    Kiwanuka, Suzanne Namusoke
    Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1363506Article in journal (Refereed)
    Abstract [en]

    Background: The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services.

    Objectives: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices.

    Methods: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The data was analysed using difference in differences (DiD) analysis and logistic regression.

    Results: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.171.74] and saving for maternal health (aOR 2.11, 95% CI 1.39-3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care.

    Conclusions: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.

  • 34. Ekirapa-Kiracho, Elizabeth
    et al.
    Namazzi, Gertrude
    Tetui, Moses
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda.
    Mutebi, Aloysius
    Waiswa, Peter
    Oo, Htet
    Peters, David H.
    George, Asha S.
    Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda2016In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 638Article in journal (Refereed)
    Abstract [en]

    Background: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. Methods: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. Results: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women's access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. Conclusions: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.

  • 35.
    Engberg, Elisabeth
    Umeå University, Faculty of Social Sciences, Demographic Data Base.
    "Det är samhällssystemets fel": Norrskensflamman och utbrottet av Spanska sjukan i Arjeplog 19202012In: Människan, arbetet och historien: en vänbok till professor Tom Ericsson / [ed] Anders Brändström & Svante Norrhem, Umeå: Umeå universitet , 2012, p. 9-28Chapter in book (Other academic)
  • 36.
    Ericson-Lidman, Eva
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Strandberg, Gunilla
    Umeå University, Faculty of Medicine, Department of Nursing.
    Care providers learning to deal with troubled conscience through participatory action research2013In: Action Research, ISSN 1476-7503, E-ISSN 1741-2617, Vol. 11, no 4, p. 386-402Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to identify a process to assist care providers in dealing constructively with their troubled conscience generated by a difficult situation in elderly care relating to spitting behaviour. Our idea was, with help from participatory action research (PAR), that sharing and reflecting with others upon the voice of conscience, may support care providers to find ways to deal constructively with troubled conscience. Care providers in municipal elderly care participated in intervention sessions over one year, and with support from PAR, they were able to learn to ease the burden of a troubled conscience. They dealt with their troubled conscience constructively by sharing their thoughts and feelings, and gaining more knowledge about behavioural symptoms. They were trying to take relevant measures when caring for the resident, and perceiving the behaviour as unintentional. In this study PAR contributes with increased understanding of the necessity to listen to one's conscience and of the possibility of using conscience as a driving force, to develop clinical practice. This contribution of PAR may in the long run increase quality of care and work-related health.

  • 37.
    Eriksson, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Druid, Henrik
    Thiblin, Ingemar
    Löwenhielm, Peter
    ST-handledarna bör vara vetenskapligt kompetenta2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 24-25, p. 1817-1817Article in journal (Other academic)
    Abstract [sv]

    Varför särbehandlas vetenskaplig kompetens negativt jämfört med övriga områden som handledarskap, pedagogik, kommunikation och etik? Frågan ställs i detta inlägg om Socialstyrelsens förslag till föreskrifter och allmänna råd om läkarnas specialiseringstjänstgöring. Författningstexten bör justeras så att handledaren är kompetent inom alla områden, uppmanar artikelförfattarna.

  • 38.
    Eslava-Schmalbach, Javier
    et al.
    National University of Colombia.
    Sandoval-Vargas, Gisella
    National University of Colombia.
    Mosquera Mendez, Paola
    Incorporating equity into developing and implementing evidence-based clinical practice guidelines2011In: Revista de Salud Pública, ISSN 0124-0064, Vol. 13, no 2, p. 339-351Article in journal (Refereed)
    Abstract [en]

    Clinical practice guidelines (CPG) are useful tools for clinical decision making, processes standardization and quality of care improvements. The current General Social Security and Health System (GSSHS) in Colombia is promoting the initiative of developing and implementing CPG based on evidence in order to improve efficiency and quality of care. The reduction of inequalities in health should be an objective of the GSSHS. The main propose of this analysis is to argue why it is necessary to consider the incorporation of equity considerations in the development and implementation of clinical practice guidelines based on the evidence. A series of reflections were made. Narrative description was used for showing the arguments that support the main findings. Among them are: 1. Differential effectiveness by social groups of interventions could diminish final effectiveness of CPG in the GSSHS; 2. To not consider geographical, ethnic, socioeconomic, cultural and access diversity issues within the CPG could have a potential negative impacts of the CPG; 3. Overall effectiveness of GPC could be better if equity issues are included in the quality verification checklist of the guideline questions; 4. Incorporating equity issues in the process of developing CPG could be cost effective, because improve overall effectiveness of CPG. Conclusions To include equity issues in CPG can help in achieving more equitable health outcomes. From this point of view CPG could be key tools to promote equity in care and health outcomes.

  • 39. Fernandez, Andreas
    et al.
    Andén, Annika
    Forssén, Annika
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Brändström, Christina
    Flodin, Christina
    Truedsson, Maria
    Wiborgh, Meta
    Backman, Monica
    Ernstdotter, Ninni
    Svartholm, Robert
    Runeberg, Sam
    Wallmark, Stefan
    "Enkla" mått ökar risken för felorientering2010In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 107, no 17, p. 1168-Article in journal (Other academic)
  • 40. Fjelltun, Aud-Mari
    et al.
    Henriksen, Nils
    Norberg, Astrid
    Umeå University, Faculty of Medicine, Department of Nursing.
    Gilje, Fredicka
    Normann, Hans Ketil
    Functional levels and nurse workload of elderly awaiting nursing home placement and nursing home residents: a comparative study.2009In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 23, no 4, p. 736-747Article in journal (Refereed)
    Abstract [en]

    The aim of this study was twofold: to compare the functional levels of elderly awaiting nursing home placement and nursing home residents, and to compare their nurses' physical and psychological workloads. In Norway, the demand for nursing home placement has increased greatly. Elderly awaiting placement can receive care from home health care services and/or from their families. Documenting elderly's functional levels may illuminate the extent of the carers' workloads and the need for support during the waiting period. The study was conducted in 2005 on two groups in northern Norway. Using the Multi-Dimensional Dementia Assessment Scale to assess functional levels, one group of nurses assessed elderly awaiting nursing home placement (n = 36) and another group of nurses assessed nursing home residents (n = 47). The nurses also reported physical and psychological workloads in caring for these elderly. A comparison of the functional levels between elderly awaiting nursing home placement and nursing home residents showed few statistically significant differences. Nursing home residents had two lower motor functions, needed more assistance with activities of daily living, more regular administration of enemas, were more often unable to speak, and showed lower orientation levels. Clinically significant similarities were found in five motor functions, including rising from lying to sitting, rising out of bed and walking, and in behavioural and psychiatric symptoms. Both groups of elderly had a high prevalence of sadness and fearfulness. The results of this study indicate that elderly awaiting nursing home placement can be as frail as nursing home residents. These results highlight the elderly's need for assistance and reveal the need for more nursing home beds. Nurses in home health care and nursing homes rated physical and psychological workloads similarly. As many carers provide care 24 hours a day, these results also illuminate the need to support carers during the waiting period.

  • 41. Flores, Walter
    et al.
    Ruano, Ana Lorena
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Phé Funchal, Denise
    Social participation within a context of political violence: implications for the promotion and exercise of the right to health in guatemala2009In: Health and Human Rights: An International Journal, ISSN 1079-0969, E-ISSN 2150-4113, Vol. 11, no 1, p. 37-48Article in journal (Refereed)
    Abstract [en]

    Social participation has been understood in many different ways, and there are eventypologies classifying participation by the degree of a population’s control in decisionmaking. Participation can vary from a symbolic act, which does not involve decisionmaking, to processes in which it constitutes the principal tool for redistributing powerwithin a population. This article argues that analyzing social participation from a perspectiveof power relations requires knowledge of the historical, social, and economicprocesses that have characterized the social relations in a specific context. Applyingsuch an analysis to Guatemala reveals asymmetrical power relations characterized bya long history of repression and political violence. The armed conflict during the secondhalf of the 20th century had devastating consequences for a large portion of thepopulation as well as the country’s social leadership. The ongoing violence resulted innegative psychosocial effects among the population, including mistrust toward institutionsand low levels of social and political participation. Although Guatemala madeprogress in creating spaces for social participation in public policy after signing thePeace Accords in 1996, the country still faces after-effects of the conflict. One importanttask for the organizations that work in the field of health and the right to healthis to help regenerate the social fabric and to rebuild trust between the state and itscitizens. Such regeneration involves helping the population gain the skills, knowledge,and information needed in order to participate in and affect formal political processesthat are decided and promoted by various public entities, such as the legislative andexecutive branches, municipal governments, and political parties. This process alsoapplies to other groups that build citizenship through participation, such as neighborhoodorganizations and school and health committees.

  • 42.
    Forsell, N.
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Holzmann, M.
    Taki, H.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Eriksson, A.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Forensic Medicine.
    Ruge, Toralph
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Transport time from crash scene may influence survival2017In: Trauma, ISSN 1460-4086, E-ISSN 1477-0350, Vol. 19, no 1, p. 77-78Article in journal (Refereed)
  • 43.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Indian Institute of Technology – Madras, Centre of Technology and Policy, Chennai, India.
    Oxman, Andrew D
    Okebukola, Peter O
    Rada, Gabriel
    Interventions to reduce corruption in the health sector2016In: Cochrane Database of Systematic Reviews, ISSN 1469-493X, E-ISSN 1469-493X, no 8, article id CD008856Article, review/survey (Refereed)
    Abstract [en]

    Background: Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to oneself; where the benefits may be financial, material or non-material. It is wide-spread in the health sector and represents a major problem.

    Objectives: Our primary objective was to systematically summarise empirical evidence of the effects of strategies to reduce corruption in the health sector. Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence.

    Search methods: We searched 14 electronic databases up to January 2014, including: CENTRAL; MEDLINE; EMBASE; sociological, economic, political and other health databases; Human Resources Abstracts up to November 2010; Euroethics up to August 2015; and PubMed alerts from January 2014 to June 2016. We searched another 23 websites and online databases for grey literature up to August 2015, including the World Bank, the International Monetary Fund, the U4 Anti-Corruption Resource Centre, Transparency International, healthcare anti-fraud association websites and trial registries. We conducted citation searches in Science Citation Index and Google Scholar, and searched PubMed for related articles up to August 2015. We contacted corruption researchers in December 2015, and screened reference lists of articles up to May 2016.

    Selection criteria: For the primary analysis, we included randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies that evaluated the effects of an intervention to reduce corruption in the health sector. For the secondary analysis, we included case studies that clearly described an intervention to reduce corruption in the health sector, addressed either our primary or secondary objective, and stated the methods that the study authors used to collect and analyse data.

    Data collection and analysis: One review author extracted data from the included studies and a second review author checked the extracted data against the reports of the included studies. We undertook a structured synthesis of the findings. We constructed a results table and 'Summaries of findings' tables. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence.

    Main results: No studies met the inclusion criteria of the primary analysis. We included nine studies that met the inclusion criteria for the secondary analysis. One study found that a package of interventions coordinated by the US Department of Health and Human Services and Department of Justice recovered a large amount of money and resulted in hundreds of new cases and convictions each year (high certainty of the evidence). Another study from the USA found that establishment of an independent agency to investigate and enforce efforts against overbilling might lead to a small reduction in overbilling, but the certainty of this evidence was very low. A third study from India suggested that the impacts of coordinated efforts to reduce corruption through increased detection and enforcement are dependent on continued political support and that they can be limited by a dysfunctional judicial system (very low certainty of the evidence). One study in South Korea and two in the USA evaluated increased efforts to investigate and punish corruption in clinics and hospitals without establishing an independent agency to coordinate these efforts. It is unclear whether these were effective because the evidence is of very low certainty. One study from Kyrgyzstan suggested that increased transparency and accountability for co-payments together with reduction of incentives for demanding informal payments may reduce informal payments (low certainty of the evidence). One study from Germany suggested that guidelines that prohibit hospital doctors from accepting any form of benefits from the pharmaceutical industry may improve doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty of the evidence). A study in the USA, evaluated the effects of introducing a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. Another study in the USA evaluated the effects of a variety of internal control mechanisms used by community health centres to stop corruption. The effects of these strategies is unclear because the evidence was of very low certainty.

    Authors' conclusions: There is a paucity of evidence regarding how best to reduce corruption. Promising interventions include improvements in the detection and punishment of corruption, especially efforts that are coordinated by an independent agency. Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry, internal control practices in community health centres, and increased transparency and accountability for co-payments combined with reduced incentives for informal payments. The extent to which increased transparency alone reduces corruption is uncertain. There is a need to monitor and evaluate the impacts of all interventions to reduce corruption, including their potential adverse effects.

  • 44.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Corcoran, K.
    Virhage, M.
    Anell, B.
    Estimating the Value of A New Antibiotic: A Novel Approach Using Esbl As A Case Study2016Conference paper (Refereed)
  • 45.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Dibbern, T.
    Virhage, M.
    Medin, E.
    Swedish Perspective on Health Technology Assessments with Incrementally Lower Costs and Effects2016Conference paper (Refereed)
  • 46.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Henriksson, M.
    Schmitt-Egenolf, Marcus
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology.
    The Relationship Between Disease Severity and Quality of Life In Patients With Moderate to Severe Psoriasis2015In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 18, no 7, p. A675-A675Article in journal (Refereed)
  • 47.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology. PAREXEL Int, Stockholm, Sweden.
    Henriksson, Martin
    Linköping Univ, Dept Med & Hlth Sci, Linköping, Sweden.
    Schmitt-Egenolf, Marcus
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology.
    How is disease severity associated with quality of life in psoriasis patients?: Evidence from a longitudinal population-based study in Sweden2017In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 15, no 1, article id 151Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Assessing the impact of disease severity on generic quality of life (QOL) is a critical step in outcomes research and in the development of decision-analytic models structured around health states defined by clinical measures. While data from routine clinical practice found in healthcare registers are increasingly used for research, more attention should be paid to understanding the relationship between clinical measures of disease severity and QOL. The purpose of this work was therefore to investigate this relationship in psoriasis using a population-based dataset.

    METHODS: Severity was measured by the Psoriasis Area and Severity Index (PASI), which combines severity of erythema, induration, and desquamation into a single value ranging from 0 to 72. The generic EQ-5D-3L utility instrument, under the UK tariff, was used to measure QOL. The association between PASI and EQ-5D-3L was estimated using a population-based dataset of 2674 patients with moderate to severe psoriasis enrolled over ten years in the Swedish psoriasis register (PsoReg). Given the repeated measurement of patients in the register data, a longitudinal fixed-effects model was employed to control for unobserved patient-level heterogeneity.

    RESULTS: Marginal changes in PASI are associated with a non-linear response in EQ-5D-3L: Moving from PASI 10 to 9 (1 to 0) is associated with an increase of 0.0135 (0.0174) in EQ-5D-3L. Furthermore, unobserved patient-level heterogeneity appears to be an important source of confounding when estimating the relationship between QOL and PASI.

    CONCLUSIONS: Using register data to estimate the impact of disease severity on QOL while controlling for unobserved patient-level heterogeneity shows that PASI appears to have a larger impact on QOL than previously estimated. Routine collection of generic QOL data in registers should be encouraged to enable similar applications in other disease areas.

  • 48.
    Geale, Kirk
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. PAREXEL International, Stockholm, Sweden.
    Saridogan, Ertan
    Lehmann, Matthieu
    Arriagada, Pablo
    Hultberg, Marcus
    Henriksson, Martin
    Repeated intermittent ulipristal acetate in the treatment of uterine fibroids: a cost-effectiveness analysis2017In: ClinicoEconomics and Outcomes Research, ISSN 1178-6981, E-ISSN 1178-6981, Vol. 9, p. 669-676Article in journal (Refereed)
    Abstract [en]

    There are limited treatment options available for women with moderate to severe symptoms of uterine fibroids (UFs) who wish to avoid surgery. For these women, treatment with standard pharmaceuticals such as contraceptives is often insufficient to relieve symptoms, and patients may require surgery despite their wish to avoid it. Clinical trials demonstrate that ulipristal acetate 5 mg (UPA) is an effective treatment for this patient group, but its cost-effectiveness has not been assessed in this population. A decision-analytic model was developed to simulate a cohort of patients in this population under treatment with UPA followed by surgery as needed compared to treatment with iron and non-steroidal anti-inflammatory drug (NSAID) followed by surgery as needed (best supportive care, BSC). The analysis took the perspective of the National Health Service (NHS) in England, UK, and was based on the published UPA clinical trials. Results were calculated for the long-term costs and quality-adjusted life years (QALYs) for each treatment arm and combined into an incremental cost-effectiveness ratio (ICER) as the primary outcome. The impact of parameter uncertainty on the results was assessed using scenario, deterministic, and probabilistic sensitivity analyses. The results show that treating patients with the UPA strategy, instead of the BSC strategy, results in an additional cost of 1,115 pound and a gain of 0.087 QALYs, resulting in an ICER of 12,850 pound. Given commonly accepted cost-effectiveness thresholds in England, the use of UPA as a repeated, intermittent treatment for women with moderate to severe symptoms of UF wishing to avoid surgery is likely to be a cost-effective intervention when compared to BSC.

  • 49. Gerdle, Björn
    et al.
    Stålnacke, Britt-Marie
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Rehabilitation Medicine.
    Söderlund, Anne
    Åsenlöf, Pernilla
    Multimodal rehabilitation in pain too low a priority2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, no 11, p. 580-581Article in journal (Other (popular science, discussion, etc.))
  • 50.
    Ghatnekar, Ola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The burden of stroke in Sweden: studies on costs and quality of life based on Riks-Stroke, the Swedish stroke register2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The costs for stroke management and reduced health related quality of life (QoL) can extend throughout life as mental and physical disabilities are common. The aim of this thesis was to quantify this stroke-related burden with data from Riks-Stroke (RS), the Swedish stroke register.

    Costs for hospital and primary care, secondary drug prevention, home and residential care services, and production losses were estimated for first-ever stroke patients registered in the RS. The present value lifetime costs were estimated from the expected survival and discounted by 3%. Quality of life was estimated with the EQ-5D instrument on a subset of patients at 3 months after the index event and mapped to patient-reported outcome measures in the RS. Standard descriptive and analytic (multivariate regressions) statistical methods were used.

    The life-time societal present value cost per patient in 2009 was approximately €69,000 whereof home and residential care due to stroke was 59% and indirect costs for productivity losses accounted for 21% (year 2009 prices). Women had higher costs than men in all age groups. Treatment at stroke units had a low incremental cost per life-year gained compared to patients who were not treated at such facilities. The estimated disutility from stroke was greatest for women and the oldest, and compared to 1997 the cost per patient increased after a revised assumption. Hospitalisation costs were stable while long-term costs for ADL support increased in part due to a changed age structure. Patients with atrial fibrillation (AF; 24%) had €367 higher inpatient costs compared to non-AF stroke patients €8,914 (P<0.01; year 2001 prices). As the index case fatality was higher among AF patients, the cost difference was higher for patients surviving the first 28 days. A multivariate regression showed that AF, diabetes, stroke severity, and death during the 3-year follow-up period were independent cost drivers. Three regression techniques (OLS, Tobit, CLAD) were chosen for mapping EQ-5D utilities to patient-reported outcome measures in the RS. The mean utility was overestimated with all models and had lower variance than the original data.

    In conclusion, total societal lifetime cost for 22,000 first-ever stroke patients in 2009 amounted to €1.5 billion (whereof production losses were €314 million). About 56,600 QALYs were lost due to premature death and disability. Including a preference-based QoL instrument in the RS would allow cost-utility analyses, but it is important to control for confounders in comparator arms to avoid bias.

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