Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study

Objective A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed. Design and setting Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county. Subjects A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units. Main outcome measures Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL). Results In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register - they had higher HbA1c (54.9 [54.5-55.4] vs. 53.7 [53.6-53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs -1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001). Conclusion P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes. Key points A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden. Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure. Newly entered patients and data during the incentive programme were less well controlled. Missing data in a quality register can cause performance to be overestimated

Register-based evaluation of primary care - Focus on chronic disease

Background: Options for following up primary care at the regional level have increased in Sweden, partly as a result of a national reform in 2009. In Region Västra Götaland (VGR) this was the starting point for a quality initiative with about 100 indicators, using extensive healthcare registers. Aim: To perform a register-based evaluation of aspects on chronic disease management in primary care after the primary care reform in VGR. Patients and methods: The four studies were based on individual patient data from national and regional health data and quality registers. In Studies I and II, effects of pay for performance were analysed for patients and medical data in a quality register, as well as the association of inappropriate medications with the tendency to code for medication reviews. Results: Paying for data entry led to increased coverage, completeness and reliability. Paying for medication review coding was not associated with a greater reduction of inappropriate medications at highly reimbursed primary care centres than at others. In Study III, visit patterns at primary care centres in relation to blood pressure target achievement for patients with hypertension were studied. Results: Current care for hypertension was based mainly on appointments with physicians. Patients at primary care centres with more appointments with nurses than physicians reached blood pressure targets to a greater extent. In Study IV, adherence to guidelines and the potential of improvement for lipid-lowering therapy in patients with established coronary heart disease were studied. Results: Fewer than 20% of patients reached the current target for LDL cholesterol, and estimates based on a risk model showed that improved treatment could substantially reduce the number of future cardiovascular events. Conclusion: Individual-based regional data from healthcare and quality registers offer comprehensive sources of analysis of clinical practice, effects of reimbursement systems and guideline adherence for large groups of primary care patients

THIRD HAND : A solution for the fuel tank assembly at Scania Södertälje

Scania recently introduced a new fuel tank design. This new design arose a need for extra help when mounting the tank in production, which was solved with two little hooks on each tank. These hooks are today known as the current third hand solution. Not only have these hooks added additional costs, but they have also significantly compromised the work environment at the fuel tank assembly. Since an assembler can assemble up to 40 tanks in a day, even a small change would make a big difference.   The aim of this thesis was therefore to improve the work environment for the fuel tank assemblers in the production at Scania Södertälje. The aim was also to discover an alternative solution that was both financially feasible and environmentally sustainable when compared to the existing hook solution. Therefore the objective was to create a new concept for holding the fuel tank in place during assembly, taking into account cost reduction and improved safety in production. The thesis was performed at Luleå University of Technology and Scania Södertälje during spring 2023 within the topic of Industrial design engineering.   The development of the concept has been done with the user in focus, a so called human-centred/user-centred work. To reach a concept that is designed for the user, the user has been involved throughout the entire project. Additionally a lot of focus has also been on topics that will help improve the concept from a human-centred view, for example ergonomics and usability. The project followed a linear process, with iterations when needed. The phases of the project were planning, context, ideation and implementation. During the project a bunch of creative methods have been utilized to reach the best result possible. The methods are in many cases chosen because they will contribute to a human-centred design. Example of used methods are interviews, user journey, speedstorming and prototypes.   The thesis resulted in a concept for mounting the fuel tanks in production. The concept is a redesign of the existing component, support plate. The concept is taped to the tank and used in a way similar to the current hook. The fact that the new concept is similar to the hooks means an easier transition for Scania, since production won’t be needing a redesign. The new concept is both cheaper and more environmentally friendly because it is an existing component. The concept also contributes to a better work environment for several reasons. The concept has reduced the risk of the tanks dropping and hurting the assemblers. The concept also provide an easy and pain-free assembly, which causes less stress and cognitive strain for the assemblers.Scania har nyligen introducerat en ny design på sina bränsletankar. Den nya designen medförde att ett behov för extra hjälp vid upphängningen av tanken i produktion uppstod, vilket man löste med två små krokar på varje tank. Dessa krokar kallas idag för en tredje handen lösning. Användandet av krokarna har inte bara medfört en extra kostnad, men även skapat en sämre arbetsmiljö i bränsletanksmonteringen. Eftersom en montör kan montera upp till 40 tankar per dag så skulle även en liten förbättring göra stor skillnad.     Syftet med det här examensarbetet var därför att förbättra arbetsmiljön för bränsletanksmontörerna i produktion på Scania Södertälje. Syftet var också att ta fram en lösning som är både ekonomiskt fördelaktig och miljömässigt hållbar jämfört med den befintliga kroklösningen. Målet har därmed varit att utveckla ett nytt koncept för att hålla tanken på plats under monteringen, med hänsyn till minskad kostnad och ökad säkerhet i produktion. Examensarbetet utfördes vid Luleå Tekniska Universitet och Scania Södertälje under våren 2023 inom utbildningen Teknisk design.     Utvecklingen av konceptet har gjorts med fokus på användaren, ett så kallat människocentrerat/användarcentrerat arbete. För att uppnå ett koncept som är designat för användaren så har användaren involverats genom hela projektet. Utöver att involvera användaren så har mycket fokus också lagts på ämnen som hjälper till att förbättra konceptet ur ett människoperspektiv, till exempel ergonomi och användbarhet. Projektet följde en linjär process med iterationer när det behövdes. Faserna var planering, kontext undersökning, idégenerering och implementation. Under projektets gång har en mängd kreativa metoder tillämpats för att uppnå bästa möjliga resultat. Metoderna är i många fall valda för att bidra till en användarcentrerad design. Exempel på använda metoder är intervjuer, kundresa, speedstorming och prototyper.   Examensarbetet resulterade i ett koncept för upphängning av bränsletankarna i produktion. Konceptet är en om design av den existerande komponenten support plate. Konceptet tejpas fast på tanken och används på liknande sätt som kroken görs idag. Att det nya konceptet är liknande krokarna innebär en lättare övergång för Scania eftersom produktion inte behöver om designas. Det nya konceptet är både billigare och mer miljövänligt eftersom det är en existerande komponent. Konceptet bidrar också till en bättre arbetsmiljö på grund av flera orsaker. Konceptet har minskat risken att tankarna faller ner och skadar montörerna. Konceptet erbjuder även en lätt och smärtfri montering vilket skapar mindre stress och kognitiv påfrestning för montörerna

From the spread of microplastics to taking action through participation in politics and management : Stakeholders perspectives on the preconditions for implementing environmental policies with the aim to reduce the spread of microplastics from facilities containing molded rubber granules

The consequences of microplastics spreading from surfaces made from molded rubber granules has a negative impact on our ecosystems, plants, and other living organisms. As our understanding of these negative environmental impacts grows, the need to shape and enforce effective measures to reduce this spread also increases. This creates a challenge for the political environmental management on both a national and municipal level. This study investigates the condition of Swedish municipalities and the possibilities they have to take effective measures to reduce the spread of microplastics in facilities that use molded rubber granules, in a time when both knowledge and experience of molded rubber granules is still limited. The study also examines whether the municipality’s participation during the forming of new environmental policies impacts the final outcome. The theory is based on implementation and participitation in management and politics. The results are based on interviews with representatives from nine Swedish municipalities, all geographically spread out and of varying size. Even if the accountable party at the municipalities admitted that their surfaces made from molded rubber granules spread microplastics, they lacked knowledge on the spread’s environmental impact. Both lack of sufficient resources and possibility to take effective action due to politically conflicting goals, confirmed several of the challenges connected to participation and implementation within politics. The study finds that the lack of knowledge on the environmental impact of molded rubber granules, the municipalities’ limited resources and the conflicting goals between the requirements of accessibility and environmental requirements affect the municipalities’ possibilities to implement measures through an environmental policy. Through an increased cooperation between state and municipalities during the forming and implementation of environmental policies the goal fulfillments would likely improve.Effekterna av mikroplastspridning från ytor av gjutet gummigranulat påverkar både ekosystem, växter och levande organismer negativt. I takt med att förståelsen för mikroplasters negativa miljöpåverkan ökar växer behovet av att utforma och vidta effektiva åtgärder för att minska mikroplastspridningen. Detta utmanar den politiska miljöstyrningen på både statlig och kommunal nivå. Studien undersöker svenska kommuners förutsättningar för att vidta åtgärder som motverkar spridning av mikroplast från anläggningar med gjutet gummigranulat. Denna studie undersöker också hur kommuners deltagande vid utformning av nya miljöpolicys kan påverka måluppfyllnaden. Den teoretiska ramen utgörs av genomförande och deltagande inom politik och förvaltning. Resultatet baseras på intervjuer med representanter för nio geografiskt spridda svenska kommuner av varierande storlek. De ansvariga på kommunerna var medvetna om att deras ytor av gjutet gummigranulat sprider mikroplast men saknade djupare kunskap om miljöeffekterna av mikroplastspridningen. Otillräckliga ekonomiska resurser och politiska målkonflikter är några av de utmaningar som är kopplade till deltagande och genomförande inom politik och förvaltning. Kommunernas inställning till alternativa material såsom gjutet korkgranulat och åtgärder genom granulatfällor var positiv. Studien finner att bristen på kunskap om gjutet gummigranulats miljöeffekter, kommunernas resursbegränsningar och målkonflikten mellan tillgänglighetskrav och miljökrav påverkar kommunernas förutsättningar att implementera åtgärder genom en miljöpolicy. Med ett ökat deltagande genom samverkan mellan statlig och kommunal nivå vid utformning och implementering av miljöpolicys skulle måluppfyllnaden sannolikt förbättras.

THIRD HAND : A solution for the fuel tank assembly at Scania Södertälje

Scania recently introduced a new fuel tank design. This new design arose a need for extra help when mounting the tank in production, which was solved with two little hooks on each tank. These hooks are today known as the current third hand solution. Not only have these hooks added additional costs, but they have also significantly compromised the work environment at the fuel tank assembly. Since an assembler can assemble up to 40 tanks in a day, even a small change would make a big difference.   The aim of this thesis was therefore to improve the work environment for the fuel tank assemblers in the production at Scania Södertälje. The aim was also to discover an alternative solution that was both financially feasible and environmentally sustainable when compared to the existing hook solution. Therefore the objective was to create a new concept for holding the fuel tank in place during assembly, taking into account cost reduction and improved safety in production. The thesis was performed at Luleå University of Technology and Scania Södertälje during spring 2023 within the topic of Industrial design engineering.   The development of the concept has been done with the user in focus, a so called human-centred/user-centred work. To reach a concept that is designed for the user, the user has been involved throughout the entire project. Additionally a lot of focus has also been on topics that will help improve the concept from a human-centred view, for example ergonomics and usability. The project followed a linear process, with iterations when needed. The phases of the project were planning, context, ideation and implementation. During the project a bunch of creative methods have been utilized to reach the best result possible. The methods are in many cases chosen because they will contribute to a human-centred design. Example of used methods are interviews, user journey, speedstorming and prototypes.   The thesis resulted in a concept for mounting the fuel tanks in production. The concept is a redesign of the existing component, support plate. The concept is taped to the tank and used in a way similar to the current hook. The fact that the new concept is similar to the hooks means an easier transition for Scania, since production won’t be needing a redesign. The new concept is both cheaper and more environmentally friendly because it is an existing component. The concept also contributes to a better work environment for several reasons. The concept has reduced the risk of the tanks dropping and hurting the assemblers. The concept also provide an easy and pain-free assembly, which causes less stress and cognitive strain for the assemblers.Scania har nyligen introducerat en ny design på sina bränsletankar. Den nya designen medförde att ett behov för extra hjälp vid upphängningen av tanken i produktion uppstod, vilket man löste med två små krokar på varje tank. Dessa krokar kallas idag för en tredje handen lösning. Användandet av krokarna har inte bara medfört en extra kostnad, men även skapat en sämre arbetsmiljö i bränsletanksmonteringen. Eftersom en montör kan montera upp till 40 tankar per dag så skulle även en liten förbättring göra stor skillnad.     Syftet med det här examensarbetet var därför att förbättra arbetsmiljön för bränsletanksmontörerna i produktion på Scania Södertälje. Syftet var också att ta fram en lösning som är både ekonomiskt fördelaktig och miljömässigt hållbar jämfört med den befintliga kroklösningen. Målet har därmed varit att utveckla ett nytt koncept för att hålla tanken på plats under monteringen, med hänsyn till minskad kostnad och ökad säkerhet i produktion. Examensarbetet utfördes vid Luleå Tekniska Universitet och Scania Södertälje under våren 2023 inom utbildningen Teknisk design.     Utvecklingen av konceptet har gjorts med fokus på användaren, ett så kallat människocentrerat/användarcentrerat arbete. För att uppnå ett koncept som är designat för användaren så har användaren involverats genom hela projektet. Utöver att involvera användaren så har mycket fokus också lagts på ämnen som hjälper till att förbättra konceptet ur ett människoperspektiv, till exempel ergonomi och användbarhet. Projektet följde en linjär process med iterationer när det behövdes. Faserna var planering, kontext undersökning, idégenerering och implementation. Under projektets gång har en mängd kreativa metoder tillämpats för att uppnå bästa möjliga resultat. Metoderna är i många fall valda för att bidra till en användarcentrerad design. Exempel på använda metoder är intervjuer, kundresa, speedstorming och prototyper.   Examensarbetet resulterade i ett koncept för upphängning av bränsletankarna i produktion. Konceptet är en om design av den existerande komponenten support plate. Konceptet tejpas fast på tanken och används på liknande sätt som kroken görs idag. Att det nya konceptet är liknande krokarna innebär en lättare övergång för Scania eftersom produktion inte behöver om designas. Det nya konceptet är både billigare och mer miljövänligt eftersom det är en existerande komponent. Konceptet bidrar också till en bättre arbetsmiljö på grund av flera orsaker. Konceptet har minskat risken att tankarna faller ner och skadar montörerna. Konceptet erbjuder även en lätt och smärtfri montering vilket skapar mindre stress och kognitiv påfrestning för montörerna

Pay for performance associated with increased volume of medication reviews but not with less inappropriate use of medications among the elderly – an observational study

Objective: A pay for performance programme was introduced in 2009 by a Swedish county with 1.6 million inhabitants. A process measure with payment linked to coding for medication reviews among the elderly was adopted. We assessed the association with inappropriate medication for five years after baseline.Design and setting: Observational study that compared medication for elderly patients enrolled at primary care units that coded for a high or low volume of medication reviews.Patients: 144,222 individuals at 196 primary care centres, age 75 or older.Main outcome measures: Percentage of patients receiving inappropriate drugs or polypharmacy during five years at primary care units with various levels of reported medication reviews.Results: The proportion of patients with a registered medication review had increased from 3.2% to 44.1% after five years. The high-coding units performed better for most indicators but had already done so at baseline. Primary care units with the lowest payment for coding for medication reviews improved just as well in terms of inappropriate drugs as units with the highest payment – from 13.0 to 8.5%, compared to 11.6 to 7.4% and from 13.6 to 7.2% vs 11.8 to 6.5% for polypharmacy.Conclusions: Payment linked to coding for medication reviews was associated with an increase in the percentage of patients for whom a medication review had been registered. However, the impact of payment on quality improvement is uncertain, given that units with the lowest payment for medication reviews improved equally well as units with the highest payment

Visit patterns at primary care centres and individual blood pressure level – a cross-sectional study

Objective: Hypertension is a major cause of cardiovascular disease. Nevertheless, blood pressure (BP) is often inadequately treated. We studied visit patterns at primary health care centres (PHCCs) and their relation to individual BP control. Design and setting: Cross-sectional register-based study on all patients with hypertension who visited 188 PHCCs in a Swedish region. Patients: A total of 88,945 patients with uncomplicated hypertension age 40–79. Main outcome measures: Odds ratio (OR) for the individual patient to achieve the BP target of ≤140/90 mmHg. Results: Overall, 63% of patients had BP ≤ 140/90 mmHg (48% BP < 140/90). The PHCC that the patient was enrolled at and, as part of that, more nurse visits at PHCC level was associated with BP control, adjusted OR 1,10 (95% CI 1.01 to 1.21). Patients visiting PHCCs with the highest proportion of visits with nurses had an even higher chance of achieving the BP target, OR 1.19 (95% CI 1.07 to 1.32). Conclusions: In a Swedish population of patients with hypertension, about half do not achieve recommended treatment goals. Organisation of PHCC and team care are known as factors influencing BP control. Our results suggests that a larger focus on PHCC organisation including nurse based care could improve hypertension care