Enabling patient-physician continuity in Swedish primary care: the importance of a named GP.

BACKGROUND: Continuity of care is important for patients with chronic conditions. Assigning patients to a named GP may increase continuity. AIM: To examine if patients who were registered with a named GP at the onset of their first chronic disease had higher continuity at subsequent visits than patients who were only registered at a practice. DESIGN & SETTING: Registry-based observational study in Region Skåne, Sweden. The study population included 66,063 patients registered at the same practice at least 1 year before the first chronic condition onset in 2009-2015. METHOD: We compared patients registered with a named GP with patients only registered at a practice over a four-year follow-up period. The primary outcome was the Usual Provider of Care (UPC) index, for all visits and for visits related to the chronic disease. Secondary outcomes were the number of GP, nurse and out-of-hours visits, ED visits, hospital admissions, and mortality. We used linear regression models, adjusted for patient characteristics (using entropy balancing weights) and for practice-level fixed effects. RESULTS: Patients with a named GP at onset had 3-4 percentage points higher UPC, but the difference decreased and was not statistically significant after adjusting for patient and practice characteristics. Patients with a named GP made more visits, though not for the chronic condition. There were no statistically significant differences for the other outcomes. CONCLUSION: Registration with a GP at onset does not imply higher continuity at visits and is not linked to other relevant outcomes for patients diagnosed with their first chronic condition.

Trends in Remote Health Care Consumption in Sweden: Comparison Before and During the First Wave of the COVID-19 Pandemic.

BACKGROUND: Remote assessment of respiratory tract infections (RTIs) has been a controversial topic during the fast development of private telemedicine providers in Swedish primary health care. The possibility to unburden the traditional care has been put against a questionable quality of care as well as risks of increased utilization and costs. The COVID-19 pandemic has contributed to a changed management of patient care to decrease viral spread, with an expected shift in contact types from in-person to remote ones. OBJECTIVE: The main aim of this study was to compare health care consumption and type of contacts (in-person or remote) for RTIs before and during the COVID-19 pandemic. The second aim was to study whether the number of follow-up contacts after an index contact for RTIs changed during the study period, and whether the number of follow-up contacts differed if the index contact was in-person or remote. A third aim was to study whether the pattern of follow-up contacts differed depending on whether the index contact was with a traditional or a private telemedicine provider. METHODS: The study design was an observational retrospective analysis with a description of all index contacts and follow-up contacts with physicians in primary care and emergency rooms in a Swedish region (Skåne) for RTIs including patients of all ages and comparison for the same periods in 2018, 2019, and 2020. RESULTS: Compared with 2018 and 2019, there were fewer index contacts for RTIs per 1000 inhabitants in 2020. By contrast, the number of follow-up contacts, both per 1000 inhabitants and per index contact, was higher in 2020. The composition of both index and follow-up contacts changed as the share of remote contacts, in particular for traditional care providers, increased. CONCLUSIONS: During the COVID-19 pandemic in 2020, fewer index contacts for RTIs but more follow-up contacts were conducted, compared with 2018-2019. The share of both index and follow-up contacts that were conducted remotely increased. Further studies are needed to study the reasons behind the increase in remote contacts, and if it will last after the pandemic, and more clinical guidelines for remote assessments of RTI are warranted.

Patient choice, entry, and the quality of primary care: Evidence from Swedish reforms.

Policies aiming to spur quality competition among health care providers are ubiquitous, but their impact on quality is ex ante ambiguous, and credible empirical evidence is lacking in many contexts. This study contributes to the sparse literature on competition and primary care quality by examining recent competition enhancing reforms in Sweden. The reforms aimed to stimulate patient choice and entry of private providers across the country but affected markets differently depending on the initial market structure. We exploit the heterogeneous impact of the reforms in a difference-in-differences strategy, contrasting more and less exposed markets over the period 2005-2013. Although the reforms led to substantially more entry of new providers in more exposed markets, the effects on primary care quality were modest: We find small improvements of patients' overall satisfaction with care, but no consistently significant effects on avoidable hospitalisation rates or satisfaction with access to care. We find no evidence of economically meaningful quality reductions on any outcome measure.

[Telemedicine services associated with higher use of regular primary care in a Swedish region]. / Nätvårdsanvändare i Skåne kontaktade oftare vårdcentral - Användare av digitala vårdtjänster kontaktade fysiska vårdcentraler oftare än andra och gjorde inte färre akutbesök.

Since 2016, a number of companies offering primary care services via chats or video calls have entered the Swedish primary care market. This is the first study to investigate whether these services replace other primary care services or if they induce more care and potentially even increase the workload of traditional caregivers. Using administrative care register data from a Swedish region, we find that the use of telemedicine services is associated with higher use of other primary care services (visits and telephone/mail contacts). Further, telemedicine users visit the emergency room at least as often as other residents. We obtain similar results when using various strategies to account for differences between telemedicine users and non-users. However, we cannot completely rule out that an association between transitory health problems and telemedicine use explains the results.

Socioeconomic distribution of GP visits following patient choice reform and differences in reimbursement models: Evidence from Sweden.

OBJECTIVE: This study aims to analyse changes in the socioeconomic distribution of GP visits following primary care patient choice reform, and to compare their magnitude and direction in pure capitation, versus capitation/activity-based mixed, provider reimbursement settings. METHODS: We compute absolute and relative concentration indices using total population registry data from three Swedish counties (N∼3.6 million) two years pre, to two years post, reform. We decompose the indices by the contribution of first, non-recurrent and recurrent visits, and compare their changes in the different provider reimbursement settings. RESULTS: In all three counties, the number of visits increased for all population groups. Increases were larger, and distributional changes more pro-poor, in the county with mixed reimbursement. Visit increases were mostly driven by recurrent and, especially, non-recurrent, visits, which were increasingly pro-poor in all counties in absolute, but not in relative, terms. First visits either became decreasingly pro-poor, or did not change significantly. Exclusion of high users removed the pro-poor patterns in the two counties with pure capitation. CONCLUSIONS: The reform led to increased access to GP visits, but implied small changes in their socioeconomic distribution. In combination with provider reimbursement models with incentives for higher visit volumes, changes were more pro-poor over time, but it is not clear whether this was at the expense of reduced visit length or content.

Extending decomposition analysis to account for unobserved heterogeneity and persistence in health behavior: Income-related smoking inequality among Swedish women.

This article suggests an enrichment of the standard method for decomposition of the concentration index to account for unobserved heterogeneity and persistence in health behavior. As the underlying regression model in the decomposition, this approach uses a dynamic random-effect probit that both consider individual heterogeneity, using a Mundlak type of specification, and applies a simple solution to account for smoking persistence. I illustrate the suggested approach using a panel of Swedish women in Statistics Sweden's Survey of Living Conditions for one vital health-related behavior, smoking. The results highlight the importance of persistence and show that education and living in a single household are the main drivers of income-related smoking inequality.

A general method for decomposing the causes of socioeconomic inequality in health.

We introduce a general decomposition method applicable to all forms of bivariate rank dependent indices of socioeconomic inequality in health, including the concentration index. The technique is based on recentered influence function regression and requires only the application of OLS to a transformed variable with similar interpretation. Our method requires few identifying assumptions to yield valid estimates in most common empirical applications, unlike current methods favoured in the literature. Using the Swedish Twin Registry and a within twin pair fixed effects identification strategy, our new method finds no evidence of a causal effect of education on income-related health inequality.

Lies, Damned Lies, and Health Inequality Measurements: Understanding the Value Judgments.

Measuring and monitoring socioeconomic health inequalities are critical for understanding the impact of policy decisions. However, the measurement of health inequality is far from value neutral, and one can easily present the measure that best supports one's chosen conclusion or selectively exclude measures. Improving people's understanding of the often implicit value judgments is therefore important to reduce the risk that researchers mislead or policymakers are misled. While the choice between relative and absolute inequality is already value laden, further complexities arise when, as is often the case, health variables have both a lower and upper bound, and thus can be expressed in terms of either attainments or shortfalls, such as for mortality/survival.We bring together the recent parallel discussions from epidemiology and health economics regarding health inequality measurement and provide a deeper understanding of the different value judgments within absolute and relative measures expressed both in attainments and shortfalls, by graphically illustrating both hypothetical and real examples. We show that relative measures in terms of attainments and shortfalls have distinct value judgments, highlighting that for health variables with two bounds the choice is no longer only between an absolute and a relative measure but between an absolute, an attainment- relative and a shortfall-relative one. We illustrate how these three value judgments can be combined onto a single graph which shows the rankings according to all three measures, and illustrates how the three measures provide ethical benchmarks against which to judge the difference in inequality between populations.

Forgetting to remember or remembering to forget: a study of the recall period length in health care survey questions.

Self-reported data on health care use is a key input in a range of studies. However, the length of recall period in self-reported health care questions varies between surveys, and this variation may affect the results of the studies. This study uses a large survey experiment to examine the role of the length of recall periods for the quality of self-reported hospitalization data by comparing registered with self-reported hospitalizations of respondents exposed to recall periods of one, three, six, or twelve months. Our findings have conflicting implications for survey design, as the preferred length of recall period depends on the objective of the analysis. For an aggregated measure of hospitalization, longer recall periods are preferred. For analysis oriented more to the micro-level, shorter recall periods may be considered since the association between individual characteristics (e.g., education) and recall error increases with the length of the recall period.

On correcting the concentration index for binary variables.

This article discusses measurement of socioeconomic inequalities in the prevalence of a health condition, in response to the recent exchange between Guido Erreygers and Adam Wagstaff, in which they discuss the merits of their own corrections to the frequently used concentration index. We first reconcile their debate and discuss the value judgments implicit in their indices. Next, we provide a formal definition of the previously undefined value judgment in Wagstaff's correction. Finally, we show empirically that the choice of index matters, as illustrated by comparisons between countries using data from the European Survey of Health, Ageing and Retirement.

Breaking bad habits by education - smoking dynamics among Swedish women.

In a dynamic Two-Part Model (2 PM), we find the effect of previous smoking on the participation decision to be decreasing with education among Swedish women, i.e. more educated are less state dependent. However, we do not find an analogous effect of education on the conditional intensity of consumption.