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Sveréus S, Petzold M, Rehnberg C. Change in avoidable hospitalizations for low-income elders following quasi-market reform in primary care - Evidence from a natural experiment in Sweden. Soc Sci Med 2024; 346:116711. [PMID: 38430872 DOI: 10.1016/j.socscimed.2024.116711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
Quasi-market reforms have been increasingly implemented in tax-funded health care, but their effects in terms of equity, quality and socioeconomic differentials in quality remain sparsely studied. We create a natural experiment setup exploiting the differential timing of a set of quasi-market reforms - including patient choice, free establishment of providers and changes in provider remuneration -, implemented in primary care in the two largest Swedish regions (Stockholm and Västra Götaland) in 2008-2009. Using a database with individual level data from 2005 to 2009, we construct a difference-in-difference-in-differences model that compares pre to post reform changes in avoidable hospitalizations (AHs) for low-income elders and a matched comparison group, in the region exposed to, versus unexposed to, reform (total N ∼ 200 000). The results show that for low-income elders - a group dominated by older women - reform led to higher AH rates, i.e., worse primary health care quality, than what would have been the case in absence of reform. Specifically, low-income elders exposed to reform missed out on improvements in AHs seen simultaneously in the unexposed region. At the same time, the reform had on average no effect for comparable, non-low-income, peers. The fact that this pattern was specific for avoidable hospitalizations - judged as amenable to interventions in primary care -, but not present for total hospitalizations, supports that it was driven by reform implementation rather than other factors. The study contributes with high-quality empirical evidence to a policy relevant but sparsely researched area and highlights the necessity to consider differential effects of organizational changes across socioeconomic groups.
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Affiliation(s)
- Sofia Sveréus
- Department of Learning, Informatics, Management & Ethics (LIME), Karolinska Institutet, SE, 17177, Stockholm, Sweden; Stockholm Centre for Health Economics, Region Stockholm, Karolinska Institutet, Tomtebodavägen 18A, SE, 17177, Stockholm, Sweden.
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 428, SE-40530, Gothenburg, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management & Ethics (LIME), Karolinska Institutet, SE, 17177, Stockholm, Sweden; Stockholm Centre for Health Economics, Region Stockholm, Karolinska Institutet, Tomtebodavägen 18A, SE, 17177, Stockholm, Sweden
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Dahlgren C, Spånberg E, Sveréus S, Dackehag M, Wändell P, Rehnberg C. Short- and intermediate-term impact of DTC telemedicine consultations on subsequent healthcare consumption. Eur J Health Econ 2024; 25:157-176. [PMID: 36823408 PMCID: PMC9950019 DOI: 10.1007/s10198-023-01572-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/31/2023] [Indexed: 06/18/2023]
Abstract
AIM The use of direct-to-consumer (DTC) telemedicine consultations in primary healthcare has increased rapidly, in Sweden and internationally. Such consultations may be a low-cost alternative to face-to-face visits, but there is limited evidence on their effects on overall healthcare consumption. The aim of this study was to assess the short- and intermediate-term impact of DTC telemedicine consultations on subsequent primary healthcare consumption, by comparing DTC telemedicine users to matched controls in a Swedish setting. METHODS We constructed a database with individual-level data on healthcare consumption, for all residents of Region Stockholm in 2018, by linking national and regional registries. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. DTC telemedicine users were matched 1:2 to controls who were non-users of DTC telemedicine but who had a traditional face-to-face consultation during the study period. The matching criteria were diagnosis and demographic and socioeconomic variables. An interrupted time series analysis was performed to compare the healthcare consumption of DTC telemedicine users to that of the control group. RESULTS DTC telemedicine users increased their healthcare consumption more than controls. The effect seemed to be mostly short term (within a month), but was also present at the intermediate term (2-6 months after the initial consultation). The results were robust across age and disease groups. CONCLUSION The results indicate that DTC telemedicine consultations increase the total number of physician consultations in primary healthcare. From a policy perspective, it is therefore important to further investigate for which diagnoses and treatments DTC telemedicine is suitable so that its use can be encouraged when it is most cost-efficient and limited when it is not. Given the fundamentally different models for reimbursement, there are reasons to review and possibly harmonise the incentive structures for DTC telemedicine and traditional primary healthcare.
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Affiliation(s)
- Cecilia Dahlgren
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, LIME, 171 77, Stockholm, Sweden.
- Region Stockholm, Center for Health Economics, Informatics and Healthcare Research, Stockholm, Sweden.
| | - Emma Spånberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, LIME, 171 77, Stockholm, Sweden
- Region Dalarna, Department of Analysis, Falun, Sweden
| | - Sofia Sveréus
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, LIME, 171 77, Stockholm, Sweden
- Region Stockholm, Center for Health Economics, Informatics and Healthcare Research, Stockholm, Sweden
| | | | - Per Wändell
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18 A, LIME, 171 77, Stockholm, Sweden
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Williams LJ, Fletcher E, Douglas A, Anderson EDC, McCallum A, Simpson CR, Smith J, Moger TA, Peltola M, Mihalicza P, Sveréus S, Zengarini N, Campbell H, Wild SH. Retrospective cohort study of breast cancer incidence, health service use and outcomes in Europe: a study of feasibility. Eur J Public Health 2019; 28:327-332. [PMID: 29020283 DOI: 10.1093/eurpub/ckx127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Comparisons of outcomes of health care in different systems can be used to inform health policy. The EuroHOPE (European Healthcare Outcomes, Performance and Efficiency) project investigated the feasibility of comparing routine data on selected conditions including breast cancer across participating European countries. Methods Routine data on incidence, treatment and mortality by age and clinical characteristics for breast cancer in women over 24 years of age were obtained (for a calendar year) from linked hospital discharge records, cancer and death registers from Finland, the Turin metropolitan area, Scotland and Sweden (all 2005), Hungary (2006) and Norway (2009). Age-adjusted breast cancer incidence and 1-year survival were estimated for each country/region. Results In total, 24 576 invasive breast cancer cases were identified from cancer registries from over 13 million women. Age-adjusted incidence ranged from 151.1 (95%CI 147.2-155.0) in Hungary to 234.7 (95%CI 227.4-242.0)/100 000 in Scotland. One-year survival ranged from 94.1% (95%CI 93.5-94.7%) in Scotland to 97.1% (95%CI 96.2-98.1%) in Italy. Scotland had the highest proportions of poor prognostic factors in terms of tumour size, nodal status and metastases. Significant variations in data completeness for prognostic factors prevented adjustment for case mix. Conclusion Incidence of and survival from breast cancer showed large differences between countries. Substantial improvements in the use of internationally recognised common terminology, standardised data coding and data completeness for prognostic indicators are required before international comparisons of routine data can be used to inform health policy.
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Affiliation(s)
- Linda J Williams
- Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Eilidh Fletcher
- Information Services Division, NHS National Services Scotland, UK
| | - Anne Douglas
- Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | | | | | - Colin R Simpson
- Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Joel Smith
- Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Tron Anders Moger
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Mikko Peltola
- Centre for Health and Social Economics CHESS, National Institute for Health and Welfare, Finland
| | - Peter Mihalicza
- National Healthcare Service Center, Semmelweis University, Budapest, Hungary
| | - Sofia Sveréus
- Department of Learning, Informatics, Management and Ethics Medical Management Centre, Karolinska Institutet, Solna, Sweden
| | | | - Harry Campbell
- Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Sarah H Wild
- Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
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Numerato D, Fattore G, Tediosi F, Zanini R, Peltola M, Banks H, Mihalicza P, Lehtonen L, Sveréus S, Heijink R, Klitkou ST, Fletcher E, van der Heijden AA, Lundberg F, Over E, Häkkinen U, Seppälä TT. Correction: Mortality and Length of Stay of Very Low Birth Weight and Very Preterm Infants: A EuroHOPE Study. PLoS One 2017; 12:e0177040. [PMID: 28459851 PMCID: PMC5411028 DOI: 10.1371/journal.pone.0177040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Sveréus S, Larsson K, Rehnberg C. Clinic continuity of care, clinical outcomes and direct costs for COPD in Sweden: a population based cohort study. Eur Clin Respir J 2017; 4:1290193. [PMID: 28326179 PMCID: PMC5345579 DOI: 10.1080/20018525.2017.1290193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/13/2017] [Indexed: 11/24/2022] Open
Abstract
Introduction: In this study we investigate whether clinic level continuity of care (COC) for individuals with chronic obstructive pulmonary disease (COPD) is associated with better health care outcomes and lower costs in a Swedish setting. Methods: Individuals with COPD (N = 20,187) were identified through ICD-10 codes in all Stockholm County health care registries in 2007-2011 (59% female, 40% in the age group 65-74 years). We followed the individuals prospectively for 365 days after their first outpatient visit in 2012. Individual associations between COC and incidence of any hospitalization or emergency department visit and total costs for health care and pharmaceuticals were quantified by regression analysis, controlling for age, sex, comorbidity and number of visits. Clinic level COC was measured through the Bice-Boxerman COC index, grouped into quintiles. Results: At baseline, 26% of the individuals had been hospitalized at least once and 73% had dispensed at least seven prescription drugs (23% at least 16) in the last year. Patients in the lowest COC quintile (Q1) had higher probabilities of any hospitalization and any emergency department visit compared to those in Q5 (odds ratio 2.17 [95% CI 1.95-2.43] and 2.06 [1.86-2.28], respectively). Patients in Q1 also on average had 58% [95% CI: 52-64] higher costs. Conclusion: The findings show robust associations between clinic level COC and outcomes. These results verify the importance of COC, and suggest that clinic level COC is of relevance to both better outcomes for COPD patients and more efficient use of resources.
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Affiliation(s)
- Sofia Sveréus
- Department of Learning, Informatics, Management & Ethics (LIME), Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Centre for Health Economics, Informatics and Health Services, Stockholm County Council, Stockholm, Sweden
| | - Kjell Larsson
- National Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management & Ethics (LIME), Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
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Smith J, Banks H, Campbell H, Douglas A, Fletcher E, McCallum A, Moger TA, Peltola M, Sveréus S, Wild S, Williams LJ, Forbes J. Parameter Heterogeneity In Breast Cancer Cost Regressions - Evidence From Five European Countries. Health Econ 2015; 24 Suppl 2:23-37. [PMID: 26633866 PMCID: PMC5063195 DOI: 10.1002/hec.3274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 06/05/2023]
Abstract
We investigate parameter heterogeneity in breast cancer 1-year cumulative hospital costs across five European countries as part of the EuroHOPE project. The paper aims to explore whether conditional mean effects provide a suitable representation of the national variation in hospital costs. A cohort of patients with a primary diagnosis of invasive breast cancer (ICD-9 codes 174 and ICD-10 C50 codes) is derived using routinely collected individual breast cancer data from Finland, the metropolitan area of Turin (Italy), Norway, Scotland and Sweden. Conditional mean effects are estimated by ordinary least squares for each country, and quantile regressions are used to explore heterogeneity across the conditional quantile distribution. Point estimates based on conditional mean effects provide a good approximation of treatment response for some key demographic and diagnostic specific variables (e.g. age and ICD-10 diagnosis) across the conditional quantile distribution. For many policy variables of interest, however, there is considerable evidence of parameter heterogeneity that is concealed if decisions are based solely on conditional mean results. The use of quantile regression methods reinforce the need to consider beyond an average effect given the greater recognition that breast cancer is a complex disease reflecting patient heterogeneity.
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Affiliation(s)
- Joel Smith
- Health Economics Research CentreNuffield Department of Population Health, University of OxfordOxfordUK
| | - Helen Banks
- Centre for Research on Health and Social Care ManagementCERGAS, Bocconi University
| | - Harry Campbell
- Usher Institute of Population Health Sciences and InformaticsThe University of EdinburghEdinburghUK
| | - Anne Douglas
- Usher Institute of Population Health Sciences and InformaticsThe University of EdinburghEdinburghUK
| | | | | | - Tron Anders Moger
- Department of Health Management and Health Economics, Institute of Health and SocietyUniversity of OsloOsloNorway
| | - Mikko Peltola
- Centre for Health and Social Economics (CHESS)National Institute for Health and WelfareHelsinkiFinland
| | - Sofia Sveréus
- Medical Management CentreKarolinska InstitutetStockholmSweden
| | - Sarah Wild
- Usher Institute of Population Health Sciences and InformaticsThe University of EdinburghEdinburghUK
| | - Linda J. Williams
- Usher Institute of Population Health Sciences and InformaticsThe University of EdinburghEdinburghUK
| | - John Forbes
- Health Research InstituteUniversity of LimerickLimerickIreland
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Fatttore G, Numerato D, Peltola M, Banks H, Graziani R, Heijink R, Over E, Klitkou ST, Fletcher E, Mihalicza P, Sveréus S. Variations and Determinants of Mortality and Length of Stay of Very Low Birth Weight and Very Low for Gestational Age Infants in Seven European Countries. Health Econ 2015; 24 Suppl 2:65-87. [PMID: 26633869 DOI: 10.1002/hec.3261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The EuroHOPE very low birth weight and very low for gestational age infants study aimed to measure and explain variation in mortality and length of stay (LoS) in the populations of seven European nations (Finland, Hungary, Italy (only the province of Rome), the Netherlands, Norway, Scotland and Sweden). Data were linked from birth, hospital discharge and mortality registries. For each infant basic clinical and demographic information, infant mortality and LoS at 1 year were retrieved. In addition, socio-economic variables at the regional level were used. Results based on 16,087 infants confirm that gestational age and Apgar score at 5 min are important determinants of both mortality and LoS. In most countries, infants admitted or transferred to third-level hospitals showed lower probability of death and longer LoS. In the meta-analyses, the combined estimates show that being male, multiple births, presence of malformations, per capita income and low population density are significant risk factors for death. It is essential that national policies improve the quality of administrative datasets and address systemic problems in assigning identification numbers at birth. European policy should aim at improving the comparability of data across jurisdictions.
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Affiliation(s)
- Giovanni Fatttore
- Centre for Research on Health and Social Care Management, CERGAS, Bocconi University, Milan, Italy
| | - Dino Numerato
- Centre for Research on Health and Social Care Management, CERGAS, Bocconi University, Milan, Italy
- Department of Sociology,Faculty of Social Sciences, Charles University, Prague, Czech Republic
| | - Mikko Peltola
- National Institute for Health and Welfare, Centre for Health and Social Economics CHESS, Helsinki, Finland
| | - Helen Banks
- Centre for Research on Health and Social Care Management, CERGAS, Bocconi University, Milan, Italy
| | - Rebecca Graziani
- Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
- Carlo F. Dondena Centre for Research on Social Dynamics, Bocconi University, Milan, Italy
| | - Richard Heijink
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Eelco Over
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Søren Toksvig Klitkou
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | | | | | - Sofia Sveréus
- Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
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Numerato D, Fattore G, Tediosi F, Zanini R, Peltola M, Banks H, Mihalicza P, Lehtonen L, Sveréus S, Heijink R, Klitkou ST, Fletcher E, van der Heijden A, Lundberg F, Over E, Häkkinen U, Seppälä TT. Mortality and Length of Stay of Very Low Birth Weight and Very Preterm Infants: A EuroHOPE Study. PLoS One 2015; 10:e0131685. [PMID: 26121647 PMCID: PMC4488246 DOI: 10.1371/journal.pone.0131685] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 06/04/2015] [Indexed: 11/19/2022] Open
Abstract
The objective of this paper was to compare health outcomes and hospital care use of very low birth weight (VLBW), and very preterm (VLGA) infants in seven European countries. Analysis was performed on linkable patient-level registry data from seven European countries between 2006 and 2008 (Finland, Hungary, Italy (the Province of Rome), the Netherlands, Norway, Scotland, and Sweden). Mortality and length of stay (LoS) were adjusted for differences in gestational age (GA), sex, intrauterine growth, Apgar score at five minutes, parity and multiple births. The analysis included 16,087 infants. Both the 30-day and one-year adjusted mortality rates were lowest in the Nordic countries (Finland, Sweden and Norway) and Scotland and highest in Hungary and the Netherlands. For survivors, the adjusted average LoS during the first year of life ranged from 56 days in the Netherlands and Scotland to 81 days in Hungary. There were large differences between European countries in mortality rates and LoS in VLBW and VLGA infants. Substantial data linkage problems were observed in most countries due to inadequate identification procedures at birth, which limit data validity and should be addressed by policy makers across Europe.
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Affiliation(s)
- Dino Numerato
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
- * E-mail:
| | - Giovanni Fattore
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
| | - Fabrizio Tediosi
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
| | - Rinaldo Zanini
- Dipartimento Materno Infantile, Ospedale "A Manzoni", Lecco, Italy
| | - Mikko Peltola
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland
| | - Helen Banks
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
| | | | - Liisa Lehtonen
- Turku University Hospital and Turku University, Turku, Finland
| | - Sofia Sveréus
- Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Richard Heijink
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Søren Toksvig Klitkou
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Eilidh Fletcher
- Lothian Analytical Services, NHS Lothian, Edinburgh, Scotland
| | - Amber van der Heijden
- The EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Fredrik Lundberg
- Department of Neonatology, Linköping University Hospital, Linköping, Sweden
| | - Eelco Over
- National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Unto Häkkinen
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland
| | - Timo T. Seppälä
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland
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