Система с мобильным клиентом управления персоналом ОАО «Гомельский литейный завод «Центролит»

Objective: In Sweden, reports indicate surprisingly large regional variation in prescription of biological drugs, despite a growing number of clinical studies describing their beneficial effects and guidelines by professional organizations and agencies. Our objective was to ascertain whether there is also variation between individual rheumatologists in prescribing biologics to patients with rheumatoid arthritis (RA) and to evaluate reasons for treatment choices. Methods: Ten hypothetical patient cases were constructed and presented to 26 rheumatologists in five regions in Sweden. The cases were based on actual cases and were thoroughly elaborated by a senior rheumatologist and pre-tested in a pilot study. The respondents were asked whether they would treat the patients with a biological agent (YES/NO) and to explain their decisions. Results: The response rate was 26/105; 25%. Treatment choices varied considerably between the rheumatologists, some prescribing biologics to 9/10 patients and others to 2/10. In five of the ten hypothetical cases, approximately half of the respondents would prescribe biologics. No regions with particularly high or low prescription were identified. Both the decision to prescribe biologics, as well as not to prescribe, were mainly motivated by medical reasons. Some rheumatologists also referred to lifestyle-related factors or social function of the patient. Conclusion: The choice of initiation of biologics varied substantially among rheumatologists presented with hypothetical patient cases, and there were also disparities between rheumatologists practising at the same clinic. Treatment choices were primarily motivated by medical reasons. This situation raises concerns about a lack of consensus in RA treatment strategies.DOI does not work: 10.3109/03009742.2014.997286</p

Diffusion, implementation and consequences of new health technology : The cases of biological drugs for rheumatoid arthritis and the Swedish national guidelines

Improvements in health technology raise hopes for better patient outcomes and a more efficient delivery of health care. However, the processes of diffusion and implementation of new health technology have been shown to be complicated and to pose a number of challenges for the healthcare sector. Many at tempts have been made to influence and manage the introduction and diffusion of health technology. One prominent example is the Swedish nat ional guidelines that aim at influencing both clinical and political decision - making in the health sector. The overall aim of this thesis is to describe and analyze the factors influencing the diffusion and economic consequences of the introduction of a new technology with large variations in use, and to explore the process of implementation of nationally produced guidelines as an instrument for improv ing effectiveness and equity. The empirical focus is kept on the biological drugs (bDMARDs) for rheumatoid arthritis (RA), since they implied a substantial treatment change when they were first int roduced and they are relatively costly; and on the national guidelines for cardiac care, since they were the first nat ional guidelines, hence allowing a long-term perspect ive in the exploration of their implementat ion. Paper I presents a register study that uses data from national and regional registries on healt hcare use and work disability of patients with RA and shows that there was a 32 percent increase in the total fixed cost of RA during 1990-2010, mainly after the introduct ion of bDMARDs. Paper II shows that choosing to initiate treatment with bDMARDs varied substantially among 26 rheumatologists presented with hypothetical patient cases, and that there were also disparities between rheumatologists practicing in the same clinic. Paper III presents data from the Swedish Rheumatology Quality Register covering 4010 patients with RA, and shows that when using multivariate logistic regression to adjust for patient characterist ics, disease activity and t he physician’s local context, physician preference was an import ant predict or for prescription of bDMARDs. Paper IV is a qualitative study about prescribing decisions, showing that a constellat ion of various factors and their interact ion influenced the prescribing decisions according to the 26 interviewed rheumatologists. The factors included the individual rheumatologist ’s experiences and perceptions of t he evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participat ion in clinical trials. The patient as an actor emerged as an important factor. Paper V is a longitudinal qualitat ive study exploring the responses among four Swedish county councils to the national guidelines for cardiac care through 155 interviews with politicians, administ rators and clinical managers. The results show that unilateral responses to the national guidelines within the county councils have been rare, but there have been at tempts to compromise and to at tain a balance between multiple constituents. There are examples of local information meetings, the use of the national guidelines in local healthcare programs, and performing audits with the national guidelines as a base. However, performing explicit prioritizat ion as advised in the NGCC is rarely found. Over t ime, however, a more systematic use of the national guidelines has been noted. In conclusion, the diffusion of new health technology is influenced by a wide array of factors both at individual and organizational levels, as well as their interact ion. The diffusion resulted in large economic consequences and unequal access due to variations also at clinical level. Moreover, given that healthcare decision-making is influenced by many different factors, the simple influx of evidence-based guidelines will unlikely result in automat ic implementat ion. At tempts to influence healthcare decisions need to have a systems perspect ive and to account for the interact ion of factors between different actors

Alleviating poverty with new technology? : A field study of the implications of a new agriculture production methodin Zambia and the factors affecting its adoption

New technology and new innovations have for long been considered as a spring for growth. Conservation farming (CF) is a new production method introduced in rural Zambia and previous research shows that it increases yields and improves soil fertility. Even though the method is proven more efficient than conventional agriculture, only approximately 10 % of Zambia’s farmers have adopted the method. The purpose of this study is to discuss the implications of the introduction of CF on the capabilities of farmers and on economic growth. Furthermore, the study aims to explore why CF, which is proven to be more economically efficient than the conventional method, is not adopted to a larger extent in Zambia. A qualitative study of 25 farmers, farming with either CF or conventional methods, was performed in the region of Mumbwa, Zambia. The results were divided depending on whether the farmers were using the new method or not. To analyze the selected material theories were chosen that regard economic growth and technological change, the adoption process of new innovations, incentive creation and the expansion of capabilities. The two groups showed differences in age, the size of their land, how many crops they grew and to what extent they were working for others or hiring labor. The conclusion from the small sample of farmers is that the farmers using CF had been able to expand their capabilities in different ways. They had food for all the year, the new method allowed them to plan their time better and it was more environmentally sustainable than the old method. The negative aspect of CF is that it is not compatible with the old method in terms of social norms. CF leads to a more efficient use of capital and labor and therefore it can increase the economic growth. In terms of a new innovation, CF seems to have a relative advantage over the old method but it must be spread to a larger group of farmers to reach a breakthrough. To create a higher adoption rate of the method the farmers’ perception must be taken into account.Minor Field Study (Sida

Valuing health : A quantitative comparison between Person Trade Off and Time Trade Off

One must consider cost effectiveness when deciding how resources within the health sector should be distributed. Quality adjusted life years (QALYs) are used to measure the value of different medical treatments. QALY is based on utility maximization theory, which suggests that a QALY is always a QALY regardless of who receives it. Therefore, a produced QALY is worth the same regardless of the age or the initial health of the patient. Previous research has shown that these assumptions do not seem to fit the real preferences of individuals. Further, there are different methods of acquiring QALYs that give different outcomes. Two of these methods are Time Trade Off (TTO), in which respondents are confronted with a valuation of health change in time, and Person Trade Off (PTO), where respondents are confronted with a valuation in persons. Arguably, PTO is the preferred method that takes greater account of how individuals wish to allocate the resources of the society. From a distribution perspective focusing on age and initial health status, this paper aims to empirically identify the differences between TTO and PTO considering the measurement of preferences for life quality. The aim is also to examine whether the results obtained are consistent with the theoretical assumptions that are required for the preference to be accepted as a cardinal utility. A quantitative survey was carried out with 58 medical and 61 economics students. Half of the students received PTO and the other half TTO questions. The data collected was analyzed comparing the methods, the two student groups and men against women. The results from the survey show that, both with TTO and PTO, respondents on average believe that patients who are at a lower initial health level should be given priority over patients who are at a higher initial health level, and younger patients should be given priority over older patients. No significant differences were seen between PTO and TTO when it came to the age of the patient. Conversely, there was a significant difference between the methods for the valuation based on initial health status of patients. Measured with PTO a treatment for patients who are at a lower initial level is valued 28% higher than a treatment for those patients who are at a higher initial level, while the corresponding figure for TTO was 8%. Between medical students and economic students, there were significant differences in the question of age in the PTO. Between men and women differences were found in both methods.Kostnadseffektivitet är en av faktorerna som ska tas i beaktande vid beslut om hur resurser inom hälso- och sjukvården ska fördelas. Kvalitetsjusterade levnadsår (QALY) används för att mäta effekten av olika insatser. Måttet baseras på nyttomaximeringsteori vilket leder till att en QALY alltid är en QALY oavsett vem den tillfaller - med andra ord är en QALY som produceras hos en patient lika mycket värd oavsett exempelvis patientens ålder eller initiala tillstånd. Dessa antaganden har i tidigare undersökningar visat sig stämma dåligt med individers preferenser men olika metoder för att ta fram QALY verkar ta olika mycket hänsyn till dem. Två av flera metoder är Time Trade Off (TTO), där respondenter ställs inför en värdering av hälsoförändringar i tid och Person Trade Off (PTO) där respondenter ställs inför en värdering i personer. PTO har påståtts vara en mer rättvisande metod som tar större hänsyn till hur individer vill att samhälleliga resurser ska fördelas. Denna uppsats syftar till att, utifrån ett fördelningsperspektiv med fokus på ålder och initialt hälsotillstånd, empiriskt kartlägga förekomsten av skillnader i preferenser för livskvalitet mätt med PTO respektive TTO, samt att undersöka om de erhållna resultaten överensstämmer med de teoretiska grundantagandena som krävs för att preferenser ska accepteras som kardinala nyttor. För att svara mot syftet utfördes en kvantitativ undersökning på 58 läkar- samt 61 ekonomistudenter. Hälften av studenterna fick PTO-frågor och den andra hälften TTO-frågor. En statistisk bearbetning av insamlad data har gjorts där svaren har jämförts mellan metoderna samt mellan läkar- och ekonomistudenter och kvinnor och män. Resultaten från undersökningen visar att både med TTO och PTO anser respondenterna att patienter som befinner sig på en lägre initial nivå ska prioriteras framför patienter som befinner sig på en högre initial nivå samt yngre patienter ska prioriteras framför äldre patienter. Vad gäller hänsyn till patienters ålder uppmättes inga signifikanta skillnader mellan PTO och TTO. Däremot uppmättes en signifikant skillnad mellan metoderna vad gäller hänsyn till initialt hälsotillstånd hos patienter. Mätt med PTO värderas en behandling för de patienter som befinner sig på en lägre initial nivå 28 % högre än en behandling för de patienter som befinner sig på en högre initial nivå medan motsvarande siffra för TTO var 8%. Mellan läkare och ekonomer fanns signifikanta skillnader i frågan gällande ålder i PTO och mellan kvinnor och män återfanns skillnader i båda metoder

Militarização do social como estratégia de integração - o caso da UPP do Santa Marta

Neste artigo, é discutida a estratégia adotada pelo governo do Rio de Janeiro para ocupação pelo Estado das favelas que estavam sob o controle do tráfico de drogas. A estratégia de pacificação envolve um primeiro momento de ocupação militar, um segundo de instalação de uma unidade de polícia permanente no território e um terceiro que trataria de estabelecer um diálogo entre os atores sociais e canalizar as demandas para a rede de políticas. O objetivo inicial de estabelecimento de uma nova ordem policial coercitiva confronta-se, em muitos aspectos, com a construção de uma esfera pública ampliada por meio da expansão da cidadania aos moradores destes territórios e sua integração à cidade. Em estudo de caso realizado na primeira favela ocupada, o Santa Marta, evidenciamse as enormes tensões e contradições desta estratégia de ampliação dos direitos de cidadania por meio da militarização do campo social

The Need for a New Paradigm in Scandinavian Health Economics

This paper argues that the discipline of health economics has lost its way due to its persistent focus on individualistic and consequential values. The paper suggests how this might be remedied in both theory and practice. It proposes a new paradigm for health economics, which focuses on communitarian values. This new paradigm is discussed in the context of the Scandinavian welfare model

Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study

Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors

Factors influencing rheumatologists prescription of biological treatment in rheumatoid arthritis: an interview study

Background: The introduction of biological drugs involved a fundamental change in the treatment of rheumatoid arthritis (RA). The extent to which biological drugs are prescribed to RA patients in different regions in Sweden varies greatly. Previous research has indicated that differences in health care practice at the regional level might obscure differences at the individual level. The objective of this study is to explore what influences individual rheumatologists decisions when prescribing biological drugs. Method: Semi-structured interviews, utilizing closed-and open-ended questions, were conducted with senior rheumatologists, selected through a mix of random and purposive sampling. The interview questions consisted of two parts, with a "parallel mixed method" approach. In the first and main part, open-ended exploratory questions were posed about factors influencing prescription. In the second part, the rheumatologists were asked to rate predefined factors that might influence their prescription decisions. The Consolidated Framework for Implementation Research (CFIR) was used as a conceptual framework for data collection and analysis. Results: Twenty-six rheumatologists were interviewed. A constellation of various factors and their interaction influenced rheumatologists prescribing decisions, including the individual rheumatologists experiences and perceptions of the evidence, the structure of the department including responsibility for costs, peer pressure, political and administrative influences, and participation in clinical trials. The patient as an actor emerged as an important factor. Hence, factors both at organizational and individual levels influenced the prescribing of biological drugs. The factors should not be seen as individual influences but were described as influencing prescription in an interactive, nonlinear way. Conclusions: Potential factors explaining differences in prescription practice are experience and perception of the evidence on the individual level and the structure of the department and participation in clinical trials on the organizational level. The influence of patient attitudes and preferences and interpretation of scientific evidence seemed to be somewhat contradictory in the qualitative responses as compared to the quantitative rating, and this needs further exploration. An implication of the present study is that in addition to scientific knowledge, attempts to influence prescription behavior need to be multifactorial and account for interactions of factors between different actors

Rheumatoid arthritis is still expensive in the new decade: a comparison between two early RA cohorts, diagnosed 1996-98 and 2006-09

OBJECTIVES: To calculate total costs during the first year after diagnosis in 463 patients with early rheumatoid arthritis (RA) included during 2006-09 (T2) and compare the results with a similar cohort included in 1996-98 (T1). METHOD: Clinical and laboratory data were collected regularly in both cohorts, and patients completed biannual questionnaires reporting health care utilization and number of days lost from work. RESULTS: Disease activity was similar in both cohorts T1 and T2 at inclusion. Significant improvements were seen during the first year in both cohorts but were more pronounced in T2. Outpatient care increased and hospitalization decreased in T2 compared with T1. Almost 3% of patients had surgery in both cohorts, but in T2, only women had surgery. Drug costs were higher in T2 than in T1 (EUR 689 vs. EUR 435). In T2, 12% of drug costs were direct costs and 4% were total costs. The corresponding values for T1 were 9% and 3%. In T1, 50% were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion, compared to T2, where prescription was &gt; 90%. Direct costs were EUR 5716 in T2 and EUR 4674 in T1. Costs for sick leave were lower in T2 than in T1 (EUR 5490 vs. EUR 9055) but disability pensions were higher (EUR 4152 vs. EUR 2139), resulting in unchanged total costs. In T1, direct costs comprised 29% and indirect costs 71% of the total costs. The corresponding values for T2 were 37% and 63%. CONCLUSIONS: The earlier and more aggressive treatment of RA with traditional DMARDs in T2 resulted in better outcomes compared to T1. Direct costs were higher in T2, partly offset by decreased sick leave, but total costs remained unchanged.Funding agencies: Medical Research County Council of South-East Sweden (FORSS); County Council in Ostergotland</p

Costs of rheumatoid arthritis during the period 1990–2010 : a register-based cost-of-illness study in Sweden

Objectives. The objectives of this study were to analyse the total socio-economic impact of RA in Sweden during the period 1990–2010 and to analyse possible changes in costs during this period. The period was deliberately chosen to cover 10 years before and 10 years after the introduction of biologic drugs. Methods. A prevalence-based cost-of-illness study was conducted based on data from national and regional registries. Results. There was a decrease in the utilization of RA-related inpatient care as well as sick leave and disability pension during 1990–2010 in Sweden. Total costs for RA are presented in current prices as well as inflation-adjusted with the consumer price index (CPI) and a healthcare price index. The total fixed cost of RA was €454 million in 1990, adjusted to the price level of 2010 with the CPI. This cost increased to €600 million in 2010 and the increase was mainly due to the substantially increasing costs for pharmaceuticals. Of the total costs, drug costs increased from 3% to 33% between 1990 and 2010. Consequently the portion of total costs accounting for indirect costs for RA is lowered from 75% in 1990 to 58% in 2010. Conclusion. By inflation adjusting with the CPI, which is reasonable from a societal perspective, there was a 32% increase in the total fixed cost of RA between 1990 and 2010. This suggests that decreased hospitalization and indirect costs have not fallen enough to offset the increasing cost of drug treatment