Glaucoma management in Sweden -- results from a nationwide survey.

PURPOSE: To report the results from a nationwide survey on glaucoma management in Sweden, performed as a part of an Open Angle Glaucoma project conducted by the Swedish Council on Health Technology Assessment 2004-2008. METHODS: In 2005, a survey was distributed to all providers of glaucoma care in Sweden: public eye departments, public outpatient departments and private practices. The questionnaire included questions on number of examined patients, types of examinations during one defined week, internal organization and access to diagnostic equipment. The questionnaire was endorsed by the Swedish Ophthalmological Society. Reminders were sent out to nonresponders. RESULTS: Response rate was high; 97% (33/34) of eye departments, 85% (39/46) of outpatient departments and 55% (69/125) of private practices. Out of 29 282 visits in ophthalmic care during the study week, 7737 (26%) were related to glaucoma. Diagnostic equipment was generally available; all public eye facilities and 92% of private practices had at least one computerized perimeter, while equipment for fundus photography/imaging was available at 100% of eye departments, 82% of outpatient departments and 62% of private practices. The number of visual field tests and fundus images was rather low. Survey results indicate that patients on the average underwent bilateral field testing every 2nd year and fundus imaging every 8th year. CONCLUSION: Glaucoma care generated about a quarter of all patient visits in Swedish ophthalmic care. Access to diagnostic facilities was good. To meet modern standards of glaucoma care, glaucoma damage must be measured and followed more closely than at the time of the survey.

Health economic evaluations: how to find them.

OBJECTIVES: The aim of this study was to demonstrate the best way of identifying all relevant published health economic evaluation studies, which have increased in number rapidly in the past few decades. Nevertheless, health technology assessment projects are often faced with a scarcity of relevant studies. METHODS: Six bibliographic databases were searched using various individually adapted strategies. The particular example involves the cost-effectiveness of diagnosing gastroesophageal reflux disease. Inclusion and exclusion criteria were formulated. RESULTS: After irrelevant studies and duplicates had been excluded, sixty-eight abstracts were reviewed. We chose forty-one of them as relevant for full-text review, which identified fourteen papers as having met the inclusion criteria. Most of the relevant studies were identified by searching the National Health Service Economic Evaluation Database (NHS EED) and PubMed databases. CONCLUSIONS: A search in NHS EED, by means of the Cochrane Library or the Center for Reviews and Dissimination, along with a supplementary search in PubMed, is generally an appropriate, cost-effective strategy. However, because "cost-effectiveness" is not consistently indexed with Medical Subject Heading terms in PubMed, all economic search terms need to be used to fully identify the relevant references.

Hospital level of care and neonatal mortality in low- and high-risk deliveries: reassessing the question in Sweden by multilevel analysis.

BACKGROUND: In high-risk births, the availability and concentration of neonatal resources in larger regional hospitals increases the chance of survival. The advantages of regionalization for low-risk deliveries are still unclear, but some studies have suggested that regionalization also is beneficial for low risk deliveries. The aim of the present study was to investigate both the relevance of regionalization and the concentration of neonatal resources as determinants of mortality in low- and high-risk deliveries in Sweden. METHODS: Interhospital differences in 28-day neonatal mortality were analyzed distinguishing maternal and delivery factors from institutional ones. Using information from the Swedish Birth Register (1990-1995), we performed risk-stratified multilevel logistic regression analysis to study 691,742 births (first level) nested within the 66 Swedish hospitals with maternity wards (second level). RESULTS: In low-risk deliveries, mortality decreased with improved access to neonatal resources. Mortality was lowest in larger regional hospitals with full access to neonatal care. This association remained unchanged after adjusting for patient mix. With regard to high-risk deliveries, mortality was higher in large county and regional hospitals than in small hospitals without access to neonatal care but, as expected, this increased risk disappeared after adjustment for patient mix. CONCLUSIONS: Increased regionalization and concentration of neonatal resources for low-risk births is justified from a strictly medical point of view. From a public health perspective, closing small obstetrics units may prevent an appreciable number of deaths, but it would have only a very small impact on the risk of mortality from the individual's point of view. The cost-effectiveness of such a step remains to be analyzed from a health economics perspective.

Cost--effectiveness analysis of salpingectomy prior to IVF, based on a randomized controlled trial.

BACKGROUND: In patients with ultrasound-visible hydrosalpinges, salpingectomy prior to IVF increases the chance of a live birth. This study compared the cost-effectiveness of this strategy (intervention) with that of optional salpingectomy after a failed cycle (control). METHODS: Data from a Scandinavian randomized controlled trial were used to calculate the individual number of treatments and their outcomes. Only patients with ultrasound-visible hydrosalpinges were considered in the main analysis, and a maximum of three fresh cycles were included. The costs for surgical procedures, IVF treatment, medication, complications, management of pregnancy and delivery as well as of early pregnancy losses were calculated from standardized hospital charges. RESULTS: Among the 51 patients in the intervention group, the live birth rate was 60.8% compared with 40.9% in 44 controls. The average cost per patient was 13,943 euro and 12,091 euro, respectively. Thus, the average cost per live birth was 22,823 euro in the intervention group and 29,517 euro in the control group. The incremental cost-effectiveness ratio for adopting the intervention strategy was estimated at 9306 euro. CONCLUSIONS: The incremental cost to achieve the higher birth rate of the intervention strategy seems reasonable.

Waiting for orthopaedic surgery: factors associated with waiting times and patients' opinion.

OBJECTIVE: To assess waiting times for three groups of orthopaedic patients in Sweden and to identify factors explaining variations in waiting time. Also examined were factors associated with patients' perceptions that waiting times were too long. DESIGN: Retrospective study. SETTING AND STUDY PARTICIPANTS: Patients from orthopaedic units at 10 Swedish hospitals participated in the study. A questionnaire was sent to 1336 surgical patients (517 hip replacement, 321 back surgery, and 498 arthroscopic knee surgery) 3 months after surgery. Information extracted from the hospitals' patient administrative systems was also used. Outcome measures. Length of waiting time, socio-economic variables, hospital type, health-related quality of life, and opinion about waiting time. The data were analysed mainly using regression analyses. RESULTS: The overall response rate was 79%. In all pre-operative stages, waiting times were longest in the hip replacement group. Socio-economic variables were not consistent determinants of variation in waiting times except for working status in the back surgery group where working patients had shorter waiting times than non-working patients irrespective of phase of waiting time. Admission to a county/district county hospital, compared with a university/regional hospital, was associated with shorter time on the waiting list. Patients with better health-related quality of life had significantly longer waiting times for arthroscopic knee surgery by all waiting time measures. The length of wait was a significant predictor of the patients' acceptance of waiting time. Patients' influence over the date of surgery also appeared to affect their opinion about the waiting time. CONCLUSIONS: Hospital-related factors are more important than patient characteristics as explanations of variations in waiting times for orthopaedic surgery. Patients value short waiting times and the possibility of influencing the date of surgery.