Access to automated comparative feedback reports in primary care - a study of intensity of use and relationship with clinical performance among Swedish primary care practices.

BACKGROUND: Digital applications that automatically extract information from electronic medical records and provide comparative visualizations of the data in the form of quality indicators to primary care practices may facilitate local quality improvement (QI). A necessary condition for such QI to work is that practices actively access the data. The purpose of this study was to explore the use of an application that visualizes quality indicators in Swedish primary care, developed by a profession-led QI initiative ("Primärvårdskvalitet"). We also describe the characteristics of practices that used the application more or less extensively, and the relationships between the intensity of use and changes in selected performance indicators. METHODS: We studied longitudinal data on 122 primary care practices' visits to pages (page views) in the application over a period up to 5 years. We compared high and low users, classified by the average number of monthly page views, with respect to practice and patient characteristics as well as baseline measurements of a subset of the performance indicators. We estimated linear associations between visits to pages with diabetes-related indicators and the change in measurements of selected diabetes indicators over 1.5 years. RESULTS: Less than half of all practices accessed the data in a given month, although most practices accessed the data during at least one third of the observed months. High and low users were similar in terms of most studied characteristics. We found statistically significant positive associations between use of the diabetes indicators and changes in measurements of three diabetes indicators. CONCLUSIONS: Although most practices in this study indicated an interest in the automated feedback reports, the intensity of use can be described as varying and on average limited. The positive associations between the use and changes in performance suggest that policymakers should increase their support of practices' QI efforts. Such support may include providing a formalized structure for peer group discussions of data, facilitating both understanding of the data and possible action points to improve performance, while maintaining a profession-led use of applications.

Macroeconomic fluctuations and individual use of psychotropic medications: evidence from Swedish administrative data.

BACKGROUND: A growing literature finds that adult mental health worsens during economic downturns. Current insights on the relationship between macroeconomic fluctuations and psychotropic medication are based on self-reported information or aggregate measures on prescriptions. This study assesses the relationship between local macroeconomic conditions and individual use of psychotropic medication as reported in administrative registers. METHODS: We use local information on unemployment linked to individual-level longitudinal data on detailed psychotropic drug consumption from administrative registers, for individuals in working age (20-65) in Sweden 2006-13. Any psychotropic medication uptake and the related number of redeemed prescriptions are the primary outcomes. Mortality is considered a secondary outcome. RESULTS: Among young men (aged 20-44) and older women (aged 45-65), we find reduced use of psychotropic medication (2-4% compared to the mean) when the local labor market conditions deteriorate. The relationship is driven by reduced use of antidepressants. The same age-gender groups experience a significantly higher risk of mortality in bad times. CONCLUSIONS: This study shows that economic downturns may not only put strain on individuals' mental health but also on their access to psychopharmaceutic treatments.

Determinants for use of direct-to-consumer telemedicine consultations in primary healthcare-a registry based total population study from Stockholm, Sweden.

BACKGROUND: In recent years, telemedicine consultations have evolved as a new form of providing primary healthcare. Telemedicine options can provide benefits to patients in terms of access, reduced travel time and no risk of disease spreading. However, concerns have been raised that access is not equally distributed in the population, which could lead to increased inequality in health. The aim of this paper is to explore the determinants for use of direct-to-consumer (DTC) telemedicine consultations in a setting where telemedicine is included in the publicly funded healthcare system. METHODS: To investigate factors associated with the use of DTC telemedicine, a database was constructed by linking national and regional registries covering the entire population of Stockholm, Sweden (N = 2.3 million). Logistic regressions were applied to explore the determinants for utilization in 2018. As comparators, face-to-face physician consultations in primary healthcare were included in the study, as well as digi-physical physician consultations, i.e., telemedicine consultations offered by traditional primary healthcare providers also offering face-to-face visits, and telephone consultations by nurses. RESULTS: The determinants for use of DTC telemedicine differed substantially from face-to-face visits but also to some extent from the other telemedicine options. For the DTC telemedicine consultations, the factors associated with higher probability of utilization were younger age, higher educational attainment, higher income and being born in Sweden. In contrast, the main determinants for use of face-to-face visits were higher age, lower educational background and being born outside of Sweden. CONCLUSION: The use of DTC telemedicine is determined by factors that are generally not associated with greater healthcare need and the distribution raises some concerns about the equity implications. Policy makers aiming to increase the level of telemedicine consultations in healthcare should consider measures to promote access for elderly and individuals born outside of Sweden to ensure that all groups have access to healthcare services according to their needs.

Weak association between socioeconomic Care Need Index and primary care visits per registered patient in three Swedish regions.

OBJECTIVE: The objective was to examine the association between primary care consultations and a Care Need Index (CNI) used to compensate Swedish primary care practices for the extra workload associated with patients with low socioeconomic status. DESIGN: Observational study combining graphical analysis with linear regressions of cross-sectional administrative practice-level data. SETTING: Three Swedish regions, Västra Götaland, Skåne and Östergötland (3.5 million residents). Outcomes were measured in February 2018 and the CNI was computed based on data for 31 December 2017. SUBJECTS: The unit of analysis was the primary care practice (n = 390). MAIN OUTCOME MEASURES: i) Number of GP visits per registered patient; ii) Number of nurse visits per registered patient; iii) Number of morbidity-weighted GP visits per registered patient; iv) Number of morbidity-weighted nurse visits per registered patient. RESULTS: The linear associations between the CNI and GP visits per patient were positive and statistically significant (p<0.01) for both the unweighted and weighted measure in two regions, but the associations were mainly due to 10 practices with very high CNI values. The results for nurse visits varied across regions. CONCLUSIONS: For most levels of the CNI, there was no association with the number of consultations provided. This result may indicate insufficient compensation, weak incentives to spend the money, decisions to spend the money on other things than consultations, or stronger competition for patients among low-CNI practices. The result of this observational study should not be taken as evidence against the possibility that the CNI adjustment of capitation may have affected the socioeconomic equity in GP and nurse visits.Key PointsSwedish primary care practices receive extra compensation for socioeconomically deprived patients but it is unknown how this affects service provision.Practice-level data from three regions years 2017-2018 indicate weak or no relation between the socioeconomic burden and the number of physical consultations per patient.Results are similar when adjusting for patients' morbidity levels, suggesting that the weak gradient was not explained by longer consultations.The exception is that a small number of practices with very high burdens provide more consultations per patient.The results may reflect insufficient compensation, lack of incentives, or funds being spent on other things than consultations.

Debt and mental health: new insights about the relationship and the importance of the measure of mental health.

BACKGROUND: Empirical research suggests that household debt and payment difficulties are detrimental to mental health. Despite well-known measurement problems that may contaminate analyses using subjective self-reported health measures, our knowledge is very limited concerning the effect of payment difficulties on 'objective' measures of mental health. Moreover, few studies use longitudinal data to examine the relationship. This study combines rich survey data and longitudinal data from administrative registers on a representative sample of the Swedish population to examine the relationship between payment difficulties and subjective and objective measures of mental health. METHODS: We use data from a large survey of Swedish inhabitants (The Swedish Living Conditions Surveys) combined with data from administrative registers. We investigate both directions of the relationship between mental ill health and payment difficulties, controlling for previous mental health status and previous experiences of payment difficulties. We compare the association between payment difficulties and a self-reported measure of anxiety with the associations between payment difficulties and objective measures of mental ill health from a register of psychopharmaceutical drug consumption. RESULTS: Payment difficulties associate with subjectively reported mental ill health, but less to psychopharmaca use. For objective measures, we find stronger evidence of a link running from mental ill health to later payment difficulties. CONCLUSIONS: Self-reported and objective measures of mental problems may convey different messages regarding the impact of payment difficulties on mental health. Policy measures depend on whether the primary target group is individuals with severe mental problems or individuals with mild anxiety.

Does risk-adjusted payment influence primary care providers' decision on where to set up practices?

BACKGROUND: Providing equal access to health care is an important objective in most health care systems. It is especially pertinent in systems like the Swedish primary care market, where private providers are free to establish themselves in any part of the country. To improve equity in access to care, 15 out 21 county councils in Sweden have implemented risk-adjusted capitation based on the Care Need Index, which increases capitation to primary care centers with a large share of patients with unfavorable socioeconomic and demographic characteristics. Our aim is to estimate the effects of using care-need adjusted capitation on the supply of private primary care centers. METHOD: We use a dataset that combines information on all primary care centers in Sweden during 2005-2013, the payment system and other conditions for establishing new primary care centers used in the county councils, and demographic, geographic, and socioeconomic variables for low-level geographic areas. To estimate the effects of care-need adjusted capitation, we use difference-in-differences models, contrasting the development over time between areas with and without risk-adjusted capitation, and with high and low Care Need Index values. RESULTS: Risk-adjusted capitation significantly increases the number of private primary care centers in areas with relatively high Care Need Index values. The adjustment results in a changed distribution of private centers within county councils; the total number of private centers does not increase in county councils using care-need adjusted capitation. The effects are furthermore increasing over the first three years after the implementation of such capitation, and concentrated to the lower and middle range of the group of areas with high index values. CONCLUSIONS: Risk-adjusted capitation based on the Care Need Index increases the supply of private primary care centers in areas with unfavorable socioeconomic and demographic characteristics. More generally, this result indicates that risk-adjusted capitation can significantly affect private providers' establishment decisions.

Short- and intermediate-term impact of DTC telemedicine consultations on subsequent healthcare consumption.

AIM: The use of direct-to-consumer (DTC) telemedicine consultations in primary healthcare has increased rapidly, in Sweden and internationally. Such consultations may be a low-cost alternative to face-to-face visits, but there is limited evidence on their effects on overall healthcare consumption. The aim of this study was to assess the short- and intermediate-term impact of DTC telemedicine consultations on subsequent primary healthcare consumption, by comparing DTC telemedicine users to matched controls in a Swedish setting. METHODS: We constructed a database with individual-level data on healthcare consumption, for all residents of Region Stockholm in 2018, by linking national and regional registries. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. DTC telemedicine users were matched 1:2 to controls who were non-users of DTC telemedicine but who had a traditional face-to-face consultation during the study period. The matching criteria were diagnosis and demographic and socioeconomic variables. An interrupted time series analysis was performed to compare the healthcare consumption of DTC telemedicine users to that of the control group. RESULTS: DTC telemedicine users increased their healthcare consumption more than controls. The effect seemed to be mostly short term (within a month), but was also present at the intermediate term (2-6 months after the initial consultation). The results were robust across age and disease groups. CONCLUSION: The results indicate that DTC telemedicine consultations increase the total number of physician consultations in primary healthcare. From a policy perspective, it is therefore important to further investigate for which diagnoses and treatments DTC telemedicine is suitable so that its use can be encouraged when it is most cost-efficient and limited when it is not. Given the fundamentally different models for reimbursement, there are reasons to review and possibly harmonise the incentive structures for DTC telemedicine and traditional primary healthcare.

Simply the best? The impact of quality on choice of primary healthcare provider in Sweden.

OBJECTIVE: One of the more important objectives with the patient choice reform, introducing non-price competition in Swedish primary healthcare, was to improve performance and quality of care. However, in order for choice to lead to quality improvements, citizens need to consider quality aspects in their choices of provider. We hypothesize that quality of care influences choice of provider and the objective of this study is to investigate if citizens are willing to make a trade-off between distance to chosen provider and quality of care. METHODS: We use conditional logit models to analyse if quality and other provider attributes influence choice of provider. The study population includes all citizens of Region Stockholm with at least one primary healthcare contact (N ~1.4 million). RESULTS: The results show that distance is the most important factor in choosing a primary healthcare provider but that there seems to be a willingness to make a trade-off between distance and quality measures. However, other provider attributes, such as the Care Need Index of the registered population, seem to influence choice to a greater extent than quality. CONCLUSION: The results point in the same direction as the arguments behind the patient choice reform. However, the effects are marginal. To enhance quality competition, policy makers should consider making quality information at the provider level more accessible.

Productivity or discrimination? An economic analysis of excess-weight penalty in the Swedish labor market.

This article investigates the excess-weight penalty in income for men and women in the Swedish labor market, using longitudinal data. It compares two identification strategies, OLS and individual fixed effects, and distinguishes between two main sources of excess-weight penalties, lower productivity because of bad health and discrimination. For men, the analysis finds a significant obesity penalty related to discrimination when applying individual fixed effects. We do not find any significant excess-weight penalty for women.

Socioeconomic inequalities in drug utilization for Sweden: evidence from linked survey and register data.

This study analyzes the socioeconomic gradient in drug utilization. We use The Swedish Prescribed Drug Register, merged with the Survey of Living Conditions (the ULF), and the study sample consists of 8138 individuals. We find a positive education gradient (but no income gradient) in drug utilization, after controlling for health indicators. Whereas high-educated men use a larger number of drugs, high-educated women use both a larger number of drugs and more expensive drugs. For males, but not as clearly for females, we find that the education gradient is weaker for more health-related drugs but stronger for more expensive drugs. We conclude that the main reason for the education gradient in drug utilization is doctors' behaviour rather than compliance with medication and affordability of drugs.