An EU approach to health system performance assessment: Building trust and learning from each other.

EU countries have recently joined forces to carry out common work on health systems performance assessment (HSPA). After the signature of the Tallinn Charter in 2008, a small group of countries brought the issue of HSPA on the EU agenda; this led the European commission and member states to set up an expert group on HSPA in 2014. This group started by facilitating the exchange of best practices and lessons learnt, with an eye to avoiding duplications with activities of international organisations. While progressing on its work, the group broadened its scope: it stepped into concrete work on policy priorities such as the assessment of quality of care, integrated care and primary care. It also moved into the organisation of country-tailored events and of advocacy activities. We identify three main strength factors of the EU expert group on HSPA. First, it is built through a bottom-up participatory approach, which promotes a sense of ownership by the members. Second, it developed a flexible and pragmatic attitude, which makes it able to constantly adapt to emerging needs and priorities. Finally, the group positioned itself in a niche that was still to be exploited: the identification of ways to translate HSPA findings into effective policy making.

The national program on standardized cancer care pathways in Sweden: Observations and findings half way through.

In 2015, the Swedish government initiated a national cancer reform program to standardize cancer care pathways. Primary aims included shortened waiting times among patients with suspected cancer, increased patient satisfaction and reduced regional variation. The implementation phase of the program is now more than half way through and both achievements and challenges have been identified. The ongoing evaluation demonstrates that professional engagement and adjustments on the meso- and micro-level of the system are essential to achieving sustainable improvements. Waiting times have shortened for the pathways launched first, and patients are satisfied with a more transparent process. Physicians in primary care are satisfied to inform patients about the pathways but point out problems with comorbidity and complicated diagnostic procedures related to unspecific symptoms. Mechanisms and ethical considerations behind possible crowding-out effects need to be thoroughly highlighted and discussed with staff and management. The results so far appear promising but meso- and micro-levels of the system need to be more involved in the design processes.

The 2015 National Cancer Program in Sweden: Introducing standardized care pathways in a decentralized system.

Starting in 2015, the Swedish government has initiated a national reform to standardize cancer patient pathways and thereby eventually speed up treatment of cancer. Cancer care in Sweden is characterized by high survival rates and a generally high quality albeit long waiting times. The objective with the new national program to standardize cancer care pathways is to reduce these waiting times, increase patient satisfaction with cancer care and reduce regional inequalities. A new time-point for measuring the start of a care process is introduced called well-founded suspicion, which is individually designed for each cancer diagnosis. While medical guidelines are well established earlier, the standardisation is achieved by defining time boundaries for each step in the process. The cancer reform program is a collaborative effort initiated and incentivized by the central government while multi-professional groups develop the time-bound standardized care pathways, which the regional authorities are responsible for implementing. The broad stakeholder engagement and time-bound guidelines are interesting approaches to study for other countries that need to streamline care processes.

Developing the role of the drug and therapeutics committees: perceptions of chairs.

PURPOSE: According to Swedish law, every county is required to have a local drug and therapeutics committee (DTC) to contribute to safe and cost-effective drug use. The law presents merely a framework and gives no detailed instructions addressing, for example, organisation and methods. The aim of this study is to explore the variation of conceptions of the role of the DTCs among committee Chairs and to compare the results with an earlier study. DESIGN/METHODOLOGY/APPROACH: Data were collected by questionnaires and telephone interviews with committee chairs, which were analysed using a phenomenographic approach. FINDINGS: Four conceptions were identified, namely: traditional, patient-aware, influential, holistic and cooperative, which all involved prescribers. In one conception the DTC acted as an expert to decision-makers. One conception included the notion that cooperation across the bureaucratic borders was important. Patients were involved in two conceptions. Comparison with the earlier study showed a trend toward higher patient awareness and a higher agreement on DTC goals with an increased focus on quality issues. ORIGINALITY/VALUE: This study demonstrates an alternative research method bringing in new perspectives when exploring activities within healthcare. Patient involvement in the work of the DTCs is increasing, but should be further explored and developed.

Gender equity in health care in Sweden--minor improvements since the 1990s.

A report by the Swedish National Committee on Gender Disparities in Patient Care (1996) identified many shortcomings in the ability of the health sector to gear patient management and treatment to the specific needs of men and women. To promote gender equity in health care, the Committee presented several proposals relating to research, education, monitoring, and evaluation of health services and the responsibilities of health authorities. In 2002, the Swedish Government authorised the National Board of Health and Welfare to review and analyse gender equity trends in health care. Data from, e.g. the national quality registers, epidemiological health data registers, population surveys, and Patient Trust Boards were compiled to identify gender disparities in the quality and accessibility of health services. The curricula of medical universities and the policies of major research funds were reviewed, as were developments in major fields of health research. The National Board found that many of the gender disparities identified in the 1990s still exist, e.g. access to advanced evidence-based technologies such as coronary interventions. As previously, women account for around 60%, and men for 40%, of complaints, e.g. to the Patients' Advisory Committees. Many of the proposals of the National Committee have not been fully implemented by the national authorities or the county councils. We conclude that promoting gender equity in health care is an important but difficult task for health authorities. To make health services more gender sensitive a combination of strategies, including enforcement by guidelines and regulations, may be needed.

MSG lesions decrease body mass of suckling-age rats by attenuating circadian decreases of energy expenditure.

Suckling-age rats display endogenous circadian rhythmicity of metabolic rate (MR) with energy-saving, torpor-like decreases, which are sympathetically controlled and suppressed by leptin treatment. We investigated whether neonatal monosodium glutamate (MSG) treatment, known to cause arcuate nucleus damage and adult-age obesity, alters energy balance in the first two postnatal weeks. Continuously recorded MR and core temperatures (T(c)) show that MSG treatment disinhibits the periodic, sympathetically controlled, energy-saving drops of T(c) and MR. Increased energy expenditure thus explains reduced body fat at normal lean body mass found in MSG-treated pups artificially nourished identically to controls. In MSG-treated mother-reared pups, lean body mass is additionally reduced, suggesting that MSG also reduces suckling. Plasma leptin levels are similar in controls and MSG-treated pups but higher per unit of fat mass in the latter. We conclude that the postweaning development of MSG obesity and depressed thermogenesis are preceded by an early phase of increased energy expenditure with decreased fat deposition during suckling age and hypothesize cell damage in the arcuate nucleus to be involved in both.