Mikael Svensson

Regional variation in health care utilization in Sweden – the importance of demand-side factors

BackgroundDifferences in health care utilization across geographical areas are well documented within several countries. If the variation across areas cannot be explained by differences in medical need, it can be a sign of inefficiency or misallocation of public health care resources.MethodsIn this observational, longitudinal panel study we use regional level data covering the 21 Swedish regions (county councils) over 13xa0years and a random effects model to assess to what degree regional variation in outpatient physician visits is explained by observed demand factors such as health, demography and socio-economic factors.ResultsThe results show that regional mortality, as a proxy for population health, and demography do not explain regional variation in visits to primary care physicians, but explain about 50% of regional variation in visits to outpatient specialists. Adjusting for socio-economic and basic supply-side factors explains 33% of the regional variation in primary physician visits, but adds nothing to explaining the variation in specialist visits.Conclusion50–67% of regional variation remains unexplained by a large number of observable regional characteristics, indicating that omitted and possibly unobserved factors contribute substantially to the regional variation. We conclude that variations in health care utilization across regions is not very well explained by underlying medical need and demand, measured by mortality, demographic and socio-economic factors.

The Cost-Effectiveness of the KiVa Antibullying Program : Results from a Decision-Analytic Model

Bullying causes substantial suffering for children and adolescents. A number of bullying prevention programs have been advocated as effective methods for counteracting school bullying. However, there is a lack of economic evaluations of bullying prevention programs assessing the “value for money.” The aim of this study was to assess the cost-effectiveness of the Finnish bullying prevention program KiVa in comparison to “status quo” (treatment as usual) in a Swedish elementary school setting (grades 1 to 9). The cost-effectiveness analysis was carried out using a payer perspective based on a Markov cohort model. The costs of the program were measured in Swedish kronor and Euros, and the benefits were measured using two different metrics: (1) the number of victim-free years and (2) the number of quality adjusted life years (QALYs). Data on costs, probability transitions, and health-related quality of life measures were retrieved from published literature. Deterministic and probabilistic sensitivity analyses were carried out to establish the uncertainty of the cost-effectiveness results. The base-case analysis indicated that KiVa leads to an increased cost of €829 for a gain of 0.47 victim-free years per student. In terms of the cost per gained QALY, the results indicated a base-case estimate of €13,823, which may be seen as cost-effective given that it is lower than the typically accepted threshold value in Swedish health policy of around €50,000. Further research is needed to confirm the conclusions of this study, especially regarding the treatment effects of KiVa in different school contexts.

Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures

PurposeAn Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture.MethodsOne hundred patients (86 men, 14 women; mean age, 40xa0years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical nu2009=u200949, non-surgical nu2009=u200951). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient’s injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping.ResultsPre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management (pu2009=u20090.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY.ConclusionsSurgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective.Level of evidenceI.

A cost-effectiveness analysis of lowering residential radon levels in Sweden—Results from a modelling study

PURPOSEnResidential exposure to radon is considered as the second leading cause of lung cancer after smoking. The purpose of this study was to conduct a cost-effectiveness analysis of reducing the indoor radon levels in Sweden from the current reference level of 200u202fBq/m3 to the WHO suggested reference level of maximum 100u202fBq/m3.nnnMETHODSnWe constructed a decision-analytic cost-effectiveness model using input data from published literature and administrative records. The model compared the increase in economic costs to the health benefits of lower indoor radon-levels in a Swedish policy context. We estimated the cost per life-year and quality adjusted life year (QALY) gained and assessed the robustness of the results using both deterministic and probabilistic sensitivity analysis.nnnRESULTSnIncluding (excluding) costs of added life years the cost per QALY for existing homes was €130,000 (€99,000). For new homes the cost per QALY including (excluding) costs of added life years was €39,000 (€25,000).nnnCONCLUSIONSnThe results indicate that it is not cost-effective to reduce indoor radon levels from 200u202fBq/m3 to a maximum of 100u202fBq/m3 in existing homes, whereas it is cost-effective for new homes.

From loss of life to loss of years: a different view on the burden of injury fatalities in Sweden 1972–2014

BackgroundnWorldwide, about 5.8 million people die each year due to injuries. In Sweden, the corresponding number amounts to 3000. There are large differences among injury types regarding the age-profile of the fatalities and as most of them occur in older age groups, counting the absolute number of injury fatalities does not fully reflect the size of the burden of injury.nnnMethodsnUsing age- and sex-specific life expectancy tables in combination with data on external causes of injury, the number of injury fatalities in Sweden for the time period 1972-2014 is converted to a sum of potential years of life lost (PYLL). We then fit cause and group-specific spline regression models to the data to estimate temporal trends in both fatality counts and PYLL.nnnResultsnThere has been a steady reduction in the number of injury fatalities and in the sum of PYLL from the early 1970s to around the year 2000. Since then, there has been an increase in the number of injury fatalities and in the sum of PYLL. The upward trend is mainly explained by an increasing number of deaths due to poisonings and suicide, specifically among younger men.nnnConclusionsnThe increases in suicide and poisoning mortality offset the reductions in downward trending causes of injury mortality during the last decades. The share of PYLL is larger than the share of fatalities for both suicides and poisonings implying that an aging population does not cause the increase.

Estimating a constant WTP for a QALY—a mission impossible?

AbstractEconomic evaluations are an important input to decision-making and npriority-setting in the health care sector. Measuring preferences for health improvements, as the demand-side value (willingness to pay) of gaining a quality-adjusted life year (QALY), is one relevant component in the interpretation of the results from health economic evaluations. Our article addresses whether willingness to pay for a QALY (WTP-Q) is sensitive to the size of the health differences and the probability for improvement. We use data from a contingent valuation survey based on 1400 respondents conducted in the spring of 2014. The results show that the expectation of sensitivity to scope, or higher WTP to the larger expected quality of life improvement, is not supported. We find WTP-Q values that conform reasonably well to previous studies in Sweden.

Cost-effectiveness analysis of internet-mediated cognitive behavioural therapy for depression in the primary care setting: results based on a controlled trial

Objective To perform a cost-effectiveness analysis of a randomised controlled trial of internet-mediated cognitive behavioural therapy (ICBT) compared with treatment as usual (TaU) for patients with mild to moderate depression in the Swedish primary care setting. In particular, the objective was to assess from a healthcare and societal perspective the incremental cost-effectiveness ratio (ICER) of ICBT versus TaU at 12 months follow-up. Design A cost-effectiveness analysis alongside a pragmatic effectiveness trial. Setting Sixteen primary care centres (PCCs) in south-west Sweden. Participants Ninety patients diagnosed with mild to moderate depression at the PCCs. Main outcome measure ICERs calculated as (CostICBT−CostTaU)/(Health outcomeICBT−Health outcomeTaU)=ΔCost/ΔHealth outcomes, the health outcomes being changes in the Beck Depression Inventory-II (BDI-II) score and quality-adjusted life-years (QALYs). Results The total cost per patient for ICBT was 4044 Swedish kronor (SEK) (€426) (healthcare perspective) and SEK47u2009679 (€5028) (societal perspective). The total cost per patient for TaU was SEK4434 (€468) and SEK50u2009343 (€5308). In both groups, the largest cost was associated with productivity loss. The differences in cost per patient were not statistically significant. The mean reduction in BDI-II score was 13.4 and 13.8 units in the ICBT and TaU groups, respectively. The mean QALYs per patient was 0.74 and 0.79 in the ICBT and TaU groups, respectively. The differences in BDI-II score reduction and mean QALYs were not statistically significant. The uncertainty of the study estimates when assessed by bootstrapping indicated that no firm conclusion could be drawn as to whether ICBT treatment compared with TaU was the most cost-effective use of resources. Conclusions ICBT was regarded to be as cost-effective as TaU as costs, health outcomes and cost-effectiveness were similar for ICBT and TaU, both from a healthcare and societal perspective. Trial registration number ID NR 30511.

Long-term outcome of stenting for atherosclerotic renal artery stenosis and the effect of angiographic restenosis

Background Symptomatic renal artery stenosis (RAS) is mainly treated with pharmacological blood pressure control, sometimes with percutaneous transluminal renal angioplasty (PTRA). It is unclear if PTRA benefits these patients over time. Purpose To determine long-term renal function, morbidity, and mortality in patients with symptomatic RAS treated with PTRA, and whether long-term outcomes are associated with angiographic restenosis. Material and Methods Retrospective single-center, long-term follow-up of 57 patients with atherosclerotic RAS treated with PTRA with stent during 1995–2004 and investigated for restenosis with angiography after one year. Outcomes were retrieved from medical records and from mandatory healthcare registries. Mortality rates were related to expected survival in an age- and gender-matched population, using a life-table database. Surviving patients were assessed with blood pressures, laboratory tests, duplex ultrasonography, and radioisotope renography. Results Median follow-up was 11 years 7 months. Major indications for PTRA were therapy-resistant hypertension and declining renal function. Angiographic restenosis at one year was found in 21 of 57 patients (37%). Thirty-six patients (60%) died during follow-up. Main cause of death was cardiovascular events (54%). Mortality was significantly increased, and morbidity and healthcare utilization were high. Hypertension control during follow-up was stable with persistent need for anti-hypertensive medication, and renal function remained moderately reduced with no long-term difference between patients with vs. without restenosis. Conclusion Long-term prognosis after PTRA for atherosclerotic RAS is dismal, with high mortality and morbidity and reduced renal function, despite maintained hypertension control. Restenosis does not appear to affect late outcome.

Classmate characteristics, class composition and children’s perceived classroom climate

AimA beneficial classroom climate is vital for school achievements, health, well-being, and school satisfaction. However, there is little knowledge as to how the classmate characteristics and class composition are related to the level of a perceived messy and disorderly classroom climate and whether the estimated relationships vary between different groups of children. The aim of the study was to explore the relationship between classmate characteristics as well as class composition and children’s perceived classroom climate.MethodData from a cross-sectional survey administrated in 71 classes including 1,247 children in a mid-sized Swedish city were used. The analyses were conducted using multilevel models.ResultsA class with a higher proportion of girls was associated with a lower likelihood of perceiving the classroom climate as messy and disorderly. Moreover, a higher proportion of immigrant children in a class was associated with a perception of a messier and disorderly classroom climate among non-immigrant children, but not among immigrant children themselves.ConclusionClassmate characteristics and class composition deserve more research attention and can be important considerations when aiming to improve the classroom climate and children’s well-being in general.