Pay for performance associated with increased volume of medication reviews but not with less inappropriate use of medications among the elderly - an observational study.

OBJECTIVE: A pay for performance programme was introduced in 2009 by a Swedish county with 1.6 million inhabitants. A process measure with payment linked to coding for medication reviews among the elderly was adopted. We assessed the association with inappropriate medication for five years after baseline. DESIGN AND SETTING: Observational study that compared medication for elderly patients enrolled at primary care units that coded for a high or low volume of medication reviews. PATIENTS: 144,222 individuals at 196 primary care centres, age 75 or older. MAIN OUTCOME MEASURES: Percentage of patients receiving inappropriate drugs or polypharmacy during five years at primary care units with various levels of reported medication reviews. RESULTS: The proportion of patients with a registered medication review had increased from 3.2% to 44.1% after five years. The high-coding units performed better for most indicators but had already done so at baseline. Primary care units with the lowest payment for coding for medication reviews improved just as well in terms of inappropriate drugs as units with the highest payment - from 13.0 to 8.5%, compared to 11.6 to 7.4% and from 13.6 to 7.2% vs 11.8 to 6.5% for polypharmacy. CONCLUSIONS: Payment linked to coding for medication reviews was associated with an increase in the percentage of patients for whom a medication review had been registered. However, the impact of payment on quality improvement is uncertain, given that units with the lowest payment for medication reviews improved equally well as units with the highest payment.

Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study.

OBJECTIVE: A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed. DESIGN AND SETTING: Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county. SUBJECTS: A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units. MAIN OUTCOME MEASURES: Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL). RESULTS: In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register - they had higher HbA1c (54.9 [54.5-55.4] vs. 53.7 [53.6-53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs -1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001). CONCLUSION: P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes. Key points A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden. Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure. Newly entered patients and data during the incentive programme were less well controlled. Missing data in a quality register can cause performance to be overestimated.

Prospective study of pain, quality of life and the economic impact of open inguinal hernia repair.

BACKGROUND: There are variations in quality of life (QoL) and reported risk of chronic pain after inguinal hernia repair. The aim of this study was to investigate the improvement in pain and QoL after open inguinal hernia repair, and the economic impact. METHODS: Patients undergoing open mesh repair of a primary unilateral inguinal hernia were stratified depending on preoperative levels of symptoms and pain. Short Form 36 (SF-36®) and EQ-5D™ questionnaires were filled in before, and at 3 and 12 months after surgery. EQ-5D™ data, together with information on the mean value of a quality-adjusted life-year and the societal cost of hernia repair, were used to calculate the monetary value of QoL gained and the mean return on investment. RESULTS: Of 225 patients who began the study, 184 completed follow-up at 12 months. Some 77·2 per cent reported improvement in pain and 5·4 per cent reported increased pain after surgery. Significant improvement in SF-36® scores, pain scores measured on a visual analogue scale (VAS), and symptoms were found in the majority of patients, even those with mild symptoms before surgery. For the whole group, the bodily pain score increased from 56·4 before surgery to 82·6 at 12 months after hernia repair (P < 0·050), and the VAS score decreased from a median of 4 to 0 (P < 0·050). The return on investment was positive for all groups of patients, including those with mild symptoms. CONCLUSION: QoL improves after open inguinal hernia repair, with a good return on investment independent of symptom severity.

Pharmacoeconomics and clinical practice guidelines. A survey of attitudes in Swedish formulary committees.

BACKGROUND: Swedish formulary committees are expected to influence prescribing practice by establishing and issuing drug lists and clinical practice guidelines, particularly now that financial responsibility for prescription drugs has been transferred from the national to the county council level. OBJECTIVE: The purpose of this exploratory study was to identify the information sources and decision criteria that individual committee members perceive as important in establishing clinical practice guidelines. Moreover, obstacles to the increased use of pharmacoeconomic evaluations in decision-making were also identified. DESIGN AND SETTING: Data were gathered through a survey questionnaire administered in 1998 to members of central formulary committees throughout Sweden, as determined by a national register. PARTICIPANTS: 312 members of central formulary committees, of whom 69% responded. RESULTS: Treatment policies/guidelines supplied by government authorities, or found in reviewed journals, are considered the most important sources of information, and criteria associated with costs and effects are considered the most important decision criteria. The members' years of experience and their professions affect their assessments of information sources, whereas education in health economics affects their assessments of decision criteria. Committee members voiced an interest in pharmacoeconomic issues, but warned that there was neither sufficient competence among committee members nor an adequate supply of relevant studies. Furthermore, a majority of the members identified difficulty in translating study results into clinical practice guidelines and limited possibilities in comparing studies as obstacles to the increased use of pharmacoeconomic evaluations. CONCLUSIONS: The results of this survey may be useful in designing future economic evaluations and when presenting and diffusing study results.

The monopolistic integrated model and health care reform: the Swedish experience.

This article reviews recent reforms geared to creating internal markets in the Swedish health-care sector. The main purpose is to describe driving forces behind reforms, and to analyse the limitations of reforms oriented towards internal markets within a monopolistic integrated health-care model. The principal part of the article is devoted to a discussion of incentives within Swedish county councils, and of how these incentives have influenced reforms in the direction of more choices for consumers and a separation between purchasers and providers. It is argued that the current incentives, in combination with criticism against county council activities in the early 1990's, account for the present inconsistencies as regards reforms. Furthermore, the article maintains that a weak form of separation between purchasers and providers will lead to distorted incentives, restricting innovative behaviour and structural change. In conclusion, the process of reforming the Swedish monopolistic integrated health-care model in the direction of some form of internal market is said to rest on shaky ground.

Health outcome measures used in cost-effectiveness studies: a review of original articles published between 1986 and 1996.

Theoretically, the preferred type of health economic evaluation is the cost-benefit approach in which costs as well as benefits are measured in monetary units. This type of analysis is rarely found in practice, however, where cost-effectiveness analysis (CEA), cost-utility analysis (CUA) and other forms of economic evaluations are instead favored. The use of quality adjusted life-years (QALYs) or life-years gained, if applicable, is generally recommended in CUA/CEA because these measures will make possible broad comparisons with other studies as well as with norms regarding society's willingness-to-pay for health benefits. The purpose of this paper is to study the choice of health outcome measures and the extent to which results from CUA and CEA are discussed from such a willingness-to-pay perspective. Based on the analysis of a sample of 455 studies included in the Health Economic Evaluations Database (HEED), it is concluded that major differences exist in the choice of health outcome measures across disease categories. There is no evidence that QALYs or life-years gained have become more common over the years and CEAs using intermediary outcome measures are as common as those using life-years gained. Furthermore, studies using QALYs or life-years gained often lack a relevant discussion of society's willingness-to-pay per QALY or life-years gained.

Choice and participation in the health services: a survey of preferences among Swedish residents.

Extending the possibilities for health-service consumers to choose among providers has been an important objective on the political agenda in Sweden and elsewhere. Little is known, however, about individual and group preferences concerning the demand for choices. It is often implicitly assumed that individuals can be treated as a group with similar values and demands, but is this true? To what extent do individuals want more options in health care? Do preferences vary depending on age, education and place of living? This article explores these questions, starting from a survey of 2,000 residents in four Swedish counties. The results of the survey point to many similarities, but also indicate important differences among residents. In particular, preferences seem to vary significantly depending on age and level of education. On the other hand, older people are more favourably inclined towards the free choice of physician. On the other hand, members of the younger generation, as well as well-educated residents, demand a more active part in the process of medical decision making. These differences, as well as expectations from younger generations, pose a great challenge to the future management of health services.

Patient views on choice and participation in primary health care.

Within modern health care, much attention is given to the tasks of identifying patient preferences and then delivering health care services accordingly. Standardised solutions are not always acceptable to patients with divergent needs and preferences, and the growing number of treatment alternatives makes patient participation increasingly important. In order to identify individual preferences for choice and shared decision making, a survey was conducted among 1543 primary care patients in Sweden. As suggested by earlier work, special attention was paid to the strong link between patient preferences and age. Results show both similarities and differences in attitudes among young and old patient groups, and differences could be explained by a combination of life-cycle effects, cohort effects and expectations ensuing from the need for future health care contacts.

[International comparisons of health care resources. Expenditure shared the GNP is inadequate. Complementary real measures are necessary]. / Jämförelser av sjukvårdsresurser i olika länder. Mäta BNP-andel inte nog reala mått kompletterar.

Since the health care expenditure share of the GNP (gross national product) is a measure difficult to interpret, its use can yield erroneous results in comparing health care sector development in different countries. A complementary measure of health care resources is the size and structure of the health care labour force. Information from Sweden, Denmark, the United Kingdom and the USA shows that development in expenditure share of the GNP in no way reflects development in labour resources in the respective countries. Ranking of national costs differs depending on the measures used, which is partly to be explained by differences in relative prices in terms of various investment factors--e.g., salaries of qualified personnel. The generally slow wages trend in the Swedish health care sector is a contributory factor explaining why the marked increase in the labour force during the 1970s and 1980s is incompletely reflected in the health care expenditure share of the GNP. Studies of personnel resources at the hospital level in the above-mentioned countries have shown marked national differences to exist in terms of working hours, service contracts and job descriptions, which further explains the differences manifest at an aggregate level.

[Toxicologic information center's hotline--well-received and cost-effective for the society]. / Giftinformationscentralens rådgivning--omtyckt och lönsam för samhället.

Our evaluation using postal and interview surveys suggests that the telephone hotline service at the Swedish Poisons Information Centre ('Giftinformationscentralen') may be cost-effective for society. Advice to physicians--which was highly regarded for its speed, competence and applicability--was time-saving and facilitated better treatment. Similarly, advice direct to households eliminated many unnecessary emergency visits. Indeed, we found that the annual costs of running the centre can be completely offset by savings in health care resources. Improved outcomes, time savings for individual households, and reduced uncertainty for both households and health care staff provide additional benefits.

International comparison of health care systems using resource profiles.

The most frequently used bases for comparing international health care resources are health care expenditures, measured either as a fraction of gross domestic product (GDP) or per capita. There are several possible reasons for this, including the widespread availability of historic expenditure figures; the attractiveness of collapsing resource data into a common unit of measurement; and the present focus among OECD member countries and other governments on containing health care costs. Despite important criticisms of this method, relatively few alternatives have been used in practice. A simple framework for comparing data underlying health care systems is presented in this article. It distinguishes measures of real resources, for example human resources, medicines and medical equipment, from measures of financial resources such as expenditures. Measures of real resources are further subdivided according to whether their factor prices are determined primarily in national or global markets. The approach is illustrated using a simple analysis of health care resource profiles for Denmark, France, Germany, Sweden, the United Kingdom, and the USA. Comparisons based on measures of both real resources and expenditures can be more useful than conventional comparisons of expenditures alone and can lead to important insights for the future management of health care systems.