Ulrika Winblad

Privatization of social services: Quality differences in Swedish elderly care

One of the major policy trends in recent decades has been the privatization of social services. This trend has also reached Sweden, a welfare state with health care and social service sectors that previously had almost no private providers. One of the most affected areas is elderly care, i.e. home-help services and residential care provided to citizens older than 65 years, where the proportion of private providers increased from 1% in 1990 to 16% in 2010. The ongoing privatization in Sweden and many other countries has raised important questions regarding the consequences of this policy transformation. In this paper, we present a cross-sectional study comparing the quality of services in private and public elderly care. Using statistics from 2007 displaying a variety of quality dimensions covering over 99% of all elderly care residents in Sweden, we were able to show that privatization is indeed associated with significant quality differences. Structural quality factors such as the number of employees per resident was significantly smaller (-9%) in private elderly care. On the other hand, the proportion of residents participating in the formulation of their care plan (+7%), the proportion of elderly with a reasonable duration between evening meal and breakfast (+15%), and the proportion of elderly offered different food alternatives (+26%) were significantly in favour of private contractors. Our conclusion is that private care providers seem to emphasize service aspects rather than structural prerequisites for good care.

Patient reactions to hospital choice in Norway, Denmark, and Sweden.

This article is a comparative study of three Scandinavian countries--Norway, Denmark, and Sweden--all of which have provided the individual patient with extensive rights to choose the hospital where he/she wishes to receive treatment. In the paper, we present an analysis of the utilization of the opportunity to choose between hospitals in these three countries. The analysis addresses two questions: (i) How many patients are exercising the right to choose between hospitals in these countries and who is making use of this opportunity? (ii) How can we explain the observed utilization pattern? The results of the study reveal clear similarities between the three countries and suggest that few patients have actually chosen their hospital. However, a gradual increase can be observed over the years. Few formal, legislative, or economic barriers exist for patients. Instead, limited knowledge amongst patients regarding reforms, combined with insufficient support from GPs and limited information, can explain why few patients choose to receive care outside of their local region.

Does undernutrition still prevail among nursing home residents

BACKGROUND & AIMS During recent years public awareness about malnutrition has increased and collective initiatives have been undertaken. Simultaneously, the number of older adults is increasing, and the elderly care has been placed under pressure. The aim was to assess the nutritional situation and one-year mortality among nursing home (NH) residents, and compare with historical data. METHODS Mini Nutritional Assessment-Short Form (MNA-SF), ADL Barthel Index (BI), Short Portable Mental Status Questionnaire (SPMSQ), EQ-5D, Charlson Comorbidity Index (CCI), and blood samples were collected from 172 NH residents (86.3 ± 8 years, 70% women). Mortality data was taken from NH records. Nutritional data from 166 NH residents (83.8 ± 8 years, 61% women) examined in 1996 was retrieved for historical comparison. RESULTS The prevalence of malnutrition was 30%, as compared to 71% in the historical data set, corresponding to a present average body mass index of 23.7 ± 5.1 compared with 22.3 ± 4.2 kg/m(2) (p < 0.01). Reduced nutritional status was associated with decline in function (p < 0.001) and cognition (p < 0.01). One-year mortality was 24%. Regression analyses indicated high age (OR = 1.09, 95% CI (1.03-1.16)), high scores in CCI (OR = 1.54, (1.19-1.99)), low BMI (OR = 2.47, (1.14-5.38)) and malnutrition (OR = 2.37, (1.07-5.26)) to be independently associated with one-year mortality. CONCLUSIONS Malnutrition still prevails and is associated with deteriorated cognition, function and increased mortality. A possible improvement in nutritional status in NH residents over time was observed.

Choice policies in Northern European health systems

This paper compares the introduction of policies to promote or strengthen patient choice in four Northern European countries - Denmark, England, the Netherlands and Sweden. The paper examines whether there has been convergence in choice policies across Northern Europe. Following Christopher Pollitts suggestion, the paper distinguishes between rhetorical (discursive) convergence, decision (design) convergence and implementation (operational) convergence (Pollitt, 2002). This leads to the following research question for the article: Is the introduction of policies to strengthen choice in the four countries characterised by discursive, decision and operational convergence? The paper concludes that there seems to be convergence among these four countries in the overall policy rhetoric about the objectives associated with patient choice, embracing both concepts of empowerment (the intrinsic value) and market competition (the instrumental value). It appears that the institutional context and policy concerns such as waiting times have been important in affecting the timing of the introduction of choice policies and implementation, but less so in the design of choice policies. An analysis of the impact of choice policies is beyond the scope of this paper, but it is concluded that further research should investigate how the institutional context and timing of implementation affect differences in how the choice policy works out in practice.

Mechanisms behind privatization: A case study of private growth in Swedish elderly care

For many years the Swedish Welfare State has been associated with a welfare model in which the public sector dominates both the provision and financing of the elderly care system. However, influenced by the ongoing trend of New Public Management, the past 15 years have been characterized by governmental regimes encouraging competition and as a result there has been a substantial increase in private providers. This case study on elderly care in Sweden provides new insights into the mechanisms behind the spread and growth of privatization. Our results show that in 1990 only 1% of the labour force in the elderly care sector was employed by private organizations, in comparison to 2003 when the private share had increased to 13%. The accompanying organizational changes have been controversial and are often criticized. In general, left-wing politicians have frequently defended the traditional welfare model dominated by public providers, whereas right-wing politicians have urged for a larger share of alternative providers. In this study, statistics between the years 1990 and 2003 were used to model the relationship between privatization and a number of economic, political and social/demographic variables. The results from regression and diffusion analysis imply that privately managed elderly care has established itself mainly in metropolitan areas dominated by right-wing regimes. Surprisingly, neighbouring municipalities tend to follow these pioneers irrespective of their political colour or economic situation. In fact, after shifting political power many of those neighbouring municipalities dominated by left-wing regimes not only maintain an abundance of private contractors but also encourage a continued process of contracting out publicly managed elderly care units. As a result, clusters of municipalities with an increasing degree of privatization arise despite political and economic differences. In conclusion, geographical proximity seems to be an important variable in addition to population density, ideology and financial situation when privatization reforms are implemented in the Swedish elderly care system.

Patient participation during hospitalization for myocardial infarction: Perceptions among patients and personnel

BACKGROUND Patient participation in healthcare decision-making and illness management has been associated with high patient satisfaction ratings and improved treatment outcomes in chronic diseases. Less is known about patient participation in acute illness, such as myocardial infarction (MI). AIM To explore and describe patient and personnel perceptions of patient participation in care processes and decision-making during hospitalization for MI. METHOD A descriptive qualitative design was used. Five thematic focus group interviews were carried out (n = 25), two with patients and three with personnel, at three Swedish hospitals in 2005. Two researchers were present during the interviews; one as facilitator and one responsible for documentation. The interviews were recorded, transcribed verbatim and analysed through a thematic stepwise method. RESULTS Five themes emerged from the interviews: the meaning of patient participation, positive outcomes, difficult situations, hindrances and facilitating factors. A shared basic assumption in all groups was that patient participation is valuable and desirable in the patient-doctor/nurse encounter in MI care. However, both staff and patients viewed patient participation primarily as information. Active involvement in medical decision-making was less emphasized. Participation was judged as especially difficult to achieve during the initial, emergency phase of MI, although the informants also stressed the need for information in this phase. Positive outcomes of patient participation mentioned were that the patient may feel more secure if involved and that he/she might be more committed to the recovery process. Hindrances were lack of time, staff and, in patients, medical knowledge. Patient characteristics could also influence the level of participation. CONCLUSION If patient participation is to be achieved in all phases of MI care, patients need to be made aware of their right to participate. Health care professionals need to develop appropriate communication skills for each phase of the MI patients hospitalization.

Is patient involvement during hospitalization for acute myocardial infarction associated with post-discharge treatment outcome? An exploratory study

Objective  To investigate whether patient involvement during hospitalization for acute myocardial infarction (MI) was associated with health and behavioural outcomes 6–10 weeks after hospital discharge.

The trade-off between choice and equity: Swedish policymakers’ arguments when introducing patient choice:

How do policymakers deal with the tension between choice and equity in healthcare? An analysis and critical examination of Swedish policymakers’ arguments when introducing legislated choice of primary care provider in 2010 shows that even when deciding on a reform with a potentially great impact on distribution of health resources, implications for equity were not systematically addressed. Effects with regards to current patterns of healthcare consumption in the population as well as existing inequalities in health outcomes were not adequately addressed. Neither was the primary are choice reform, which is based on the values of consumerism and individual choice, problematized in relation to current healthcare legislation such as the Health and Medical Services Act. Given that the values of equity and social solidarity have had such a prominent place in Swedish health policy and discourse in past decades, this is a surprising finding. In conclusion, we argue that because inequalities in health constitute one of the main challenges for public health today, the impact of healthcare reforms on equity should receive more attention in policymaking.

Staff views and behaviour regarding patient involvement in myocardial infarction care: Development and evaluation of a questionnaire

Background: Healthcare legislation in several nations now dictates the responsibility of health care professionals to involve patients in decisions concerning care and treatment. However, few studies have examined the impact of patient involvement on the work of health care professionals. A better understanding of staff views and behaviour might enhance patient involvement. Aim: The aim of this study was to develop and validate a questionnaire for measuring views and behaviour regarding patient involvement among physicians and nursing staff caring for patients with myocardial infarction. Methods: Focus groups among cardiology staff provided the basis for the construction of the questionnaire. Questionnaire validity and reliability were evaluated in a small pilot study and a larger cross-sectional study among cardiology staff at twelve Swedish hospitals. Results: The questionnaire demonstrated good validity and reliability, with two factors measuring staff views and four measuring behaviour. Conclusion: The questionnaire appears to be a useful tool for evaluating the perceptions and behaviour of physicians and nursing staff regarding patient involvement in myocardial infarction care. Use of this questionnaire may provide insight regarding areas of staff–patient interaction that need improvement, as well as implications of patient involvement for the work of each professional group on cardiology wards.

ACO-Affiliated Hospitals Reduced Rehospitalizations from Skilled Nursing Facilities Faster Than Other Hospitals

Medicares more than 420 accountable care organizations (ACOs) provide care for a considerable percentage of the elderly in the United States. One goal of ACOs is to improve care coordination and thereby decrease rates of rehospitalization. We examined whether ACO-affiliated hospitals were more effective than other hospitals in reducing rehospitalizations from skilled nursing facilities. We found a general reduction in rehospitalizations from 2007 to 2013, which suggests that all hospitals made efforts to reduce rehospitalizations. The ACO-affiliated hospitals, however, were able to reduce rehospitalizations more quickly than other hospitals. The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities. Policy makers expect that reducing readmissions to hospitals will generate major savings and improve the quality of life for the frail elderly. However, further work is needed to investigate the precise mechanisms that underlie the reduction of readmissions among ACO-affiliated hospitals.