Overview of new PhDs in the Nordic countries

Abstract

: The aim of this Ph.D. thesis was to investigate whether patient involvement in medication management during hospitalisation affects the number of dispensing errors, participants’ perceptions regarding medication and participant satisfaction, and whether self-administration of medication (SAM) offers health economic advantages. Study 1 was a feasibility and pilot study about methodological, procedural and clinical uncertainties concerning the intervention and study design. This study showed that it was feasible to perform a pragmatic randomised controlled trial (RCT) on SAM’s effects. Only minor adjustments to the intervention, exclusion criteria, recruitment procedure and outcome measures, including time measurements, were needed. Recruitment was considered satisfactory, outcome-measurement methods worked as expected and the intervention was well-accepted among patients. In Study 2, we performed a pragmatic RCT that investigated whether SAM during hospi talisation affected the number of dispensing errors and participants’ perceptions regarding medication and satisfaction. Modified disguised observation was used to observe nurses and participants when they dispensed medication. The Beliefs about Medicines Questionnaire was used to explore participants’ perceptions regarding medication. Altogether, 250 participants were recruited, and just over 1,000 opportunities for errors were observed in each study group. The study found statistically significantly fewer dispensing errors in the self-administering group; thus, letting patients self-administer their medication during hospitalisation did not compromise safety related to medication dispensing. At follow-up, participants from the intervention group perceived fewer concerns about their medication, generally found medication to be less harmful and were more satisfied with the way they received medication during hospitalisation compared with the control group. Also at follow-up, fewer deviations existed in the medication list in the intervention group compared with that of the control group. In Study 3, we performed a cost-consequence analysis of SAM. We performed a cost analysis at micro-costing level using a hospital perspective with a short-term incremental costing approach. Resource use and cost data were collected alongside the RCT study, including a study of nursing time used on dispensing, administration, SAM start-up and discharge preparation. Results from the RCT study and information on the number of readmissions and general practitioner contacts within 30 days after discharge were selected as consequences. The cost analysis showed, on average, a lower total cost per participant in the intervention group compared with that of the control group. As SAM favoured the intervention group with respect to most outcomes, the intervention was suggested to be cost-effective. Abstract: Health- economic evaluation, or simply ‘economic evaluation’, has now been applied to healthcare for over 50 years, sometimes to good effect, sometimes for ill. This Ph.D. thesis seeks to give an understanding of what ‘economic evaluation’ can offer decisio n-makers, but also sets out to acknowledge its problems and pitfalls. In addition, it applies one data-driven approach to economic evaluation, utilising records available from the Finnish Randomised Study of Screening for Prostate Cancer (FinRSPC) after 20 years of follow-up. Started in 1996, the FinRSPC is a pragmatic population-based study investigating invitation to prostate-specific antigen (PSA) -testing as a basis for mass screening to detect prostate cancer, and includes investigation of some of the effects and healthcare costs for men in the trial. used uncertainties evaluation the impacts of prostate-cancer Abstract: High age is a risk factor for most acute and chronic diseases, injuries and function disabilities, and hence, an important risk factor for nutritional problems. A great deal of elderly health care in Sweden are performed in the patient’s home environment and home health care has been transformed to more advanced medical care the last decades. The aim of this thesis was to comprehensively describe the nutritional status and its change over time in a population of older people receiving home health care. The aim includes to propose a framework for investigating and analysing the nutritional status in older people. Nutritional status was studied at enrolment in home health care and regularly followed up for three years. Patients that were 65 years or older and needed home health care for at least three months between 2012 and 2017 were asked to join the study, resulting in 69 participants (64% women). Data collection and analysis of the nutritional status was based on the proposed model for assessing the nutritional status in a comprehensive functional perspective (paper 1). The model comprises four domains that affect the nutritional status and functional outcome in a bidirectional way. In paper 2 we concluded that malnutrition, sarcopenia, frailty and dehydration are highly prevalent in the population and the most important indicators were loss of appetite and dehydration. This was confirmed in paper 3, were nutritional status was analysed with a statistical approach. A total of 103 indicators of nutritional status were reduced to 19 that were suggested to be primary investigated. Also, the paper empirically confirmed the relationship within as well as between the domains suggested in paper 1. Finally, we studied meal pattern, being a part of one of the domains (paper 4). We found indications that presence of at least one large meal (high energy intake) per day had more impact on the total daily energy and protein intake than more eating occasions during the day. Promises and mixed Abstract: Financial incentives can be an effective tool to influence behaviour in almost any context and healthcare is no exception. The healthcare market is, however complex, characterised by uncertainty, information asymmetry and multiple agency connections. Some argue that financial incentives increase efficient use of scarce resources, while others voice that it provides a hotbed for unintended and unethical behaviour. A well-functioning value-based reimbursement programme (VBRP) should facilitate alignment between financial incentives and professional values to secure both efficient and equitable healthcare. This thesis explores the promises and pitfalls of value-based reimbursement in the context of elective spine surgery in Region Stockholm, Sweden. By using mixed methods, the thesis explores what incentives arise from introducing a value-based reimbursement programme and how these incentives affect the provision of healthcare services. Paper I examines the performance of healthcare providers on patient-reported outcome measures and potential effects on case mix regarding clinical and socio-economic factors. Paper II examines how a value-based reimbursement programme affects the cost of elective spine surgery to a third party payer. Paper III explores how the intended incentives of the reimbursement programme was perceived by healthcare providers. Paper IV explores the role of different professional groups in how the value-based reimbursement programme is institutionalised. The results show that the VBRP had no effect on patient-reported outcome measures but decreased the mean cost per surgery. The removal of a production ceiling allowed healthcare providers to surgically treat more patients than was previously possible. The volume increased by 22 per cent, and the total cost increased by 11 percent. No indications of discrimination against sicker patients were found. A higher value was generated in elective spine surgery after the introduction of the VBRP. The idea of a VBRP was aligned with professional values. However, not all incentives were perceived as intended. The focus on minimising costs of post-discharge care was perceived to have a negative impact on quality aspects of physiotherapy and nursing. Taken together, a well-designed VBRP has the potential to promote a holistic healthcare perspective through 1) the level to which healthcare providers are held accountable for healthcare provision that increase the willingness to collaborate across healthcare providers and medical disciplines, 2) a better overall picture of patients healthcare utilisation and 3) challenging the traditional structures and ideas within healthcare that quality foremost depends on the performance of physicians. However, there are also challenges that needs to be addressed, 1) functioning routines for communication and follow-up between healthcare providers and the regional health authority, 2) to get different professions within a traditional hierarchical organisation to cooperate on equal terms, and 3) to create IT systems that create transparency and an understanding of the reimbursement programme. Continuous communication between healthcare providers and the regional health authority is therefore crucial to make the incentives of the reimbursement programme meaningful. Abstract: Alongside maximisation of health gain equity is an important objective to consider in priority setting in publicly financed health care sectors (Costa-font & Cowell, 2019; Lane et al., 2017). The health economics literature describe equity as a multidimensional concept involving the act of measuring and judging inequalities related to the distribution of health care (Bobinac et al., 2012; Culyer, 2001; Lane et al., 2017; Williams & Cookson, 2000). In finding equitable health care distributions, decision makers must often handle inevitable trade-offs between maximisation of health gains and limiting inequalities (Olsen, 1997, Ahlert and Schwettmann, 2017). To guide decision makers on how to find equitable distributions of health care, a branch of the health economics literature applies stated preference (SP) experiments to elicit the public’s equity preferences for