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  • 1.
    Eldh, Ann Catrine
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. School of Education, Health, and Social Studies, Dalarna University, SE.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Wallin, Lars
    School of Education, Health, and Social Studies, Dalarna University, SE.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Facilitators and barriers to applying a national quality registry for quality improvement in stroke care2014In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, p. 354-Article in journal (Refereed)
    Abstract [en]

    Background: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. Methods: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. Results: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. Conclusion: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

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  • 2.
    Eldh, Ann Catrine
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Wallin, Lars
    Karolinska Institutet.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Winblad, Ulrica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Depicting the interplay between organisational tiers in the use of a national quality registry to develop quality of care in Sweden2015In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 15, no 1, article id 519Article in journal (Refereed)
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  • 3.
    Eldh, Ann Catrine
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. Dalarna Univ, Sch Hlth & Social Sci, Falun, Sweden..
    Wallin, Lars
    Dalarna Univ, Sch Hlth & Social Sci, Falun, Sweden.;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Nursing, Stockholm, Sweden..
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Factors facilitating a national quality registry to aid clinical quality improvement: findings of a national survey2016In: BMJ Open, E-ISSN 2044-6055, Vol. 6, no 11, article id e011562Article in journal (Refereed)
    Abstract [en]

    Objectives: While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement. Methods: Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression. Results: A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R-2=0.76) with 'Colleagues' call for local results' (p=<0.001), 'Management Request of Registry data' (p=<0.001), and it was said to be 'Simple to explain the results to colleagues' (p=0.02). Using stepwise regression, 'Colleagues' call for local results' was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results. Conclusions: While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.

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  • 4.
    Fredriksson, Mio
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Eldh, Ann
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Wallin, Lars
    Högskolan Dalarna.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Local politico-administrative perspectives on quality improvement based on national registry data in Sweden: a qualitative study using the Consolidated Framework for Implementation Research2014In: Implementation Science, E-ISSN 1748-5908, Vol. 9, no 1, p. 189-Article in journal (Refereed)
    Abstract [en]

    Background: Through a national policy agreement, over 167 million Euros will be invested in the Swedish National Quality Registries (NQRs) between 2012 and 2016. One of the policy agreement¿s intentions is to increase the use of NQR data for quality improvement (QI). However, the evidence is fragmented as to how the use of medical registries and the like lead to quality improvement, and little is known about non-clinical use. The aim was therefore to investigate the perspectives of Swedish politicians and administrators on quality improvement based on national registry data.MethodsPoliticians and administrators from four county councils were interviewed. A qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed.ResultsThe politicians¿ and administrators¿ perspectives on the use of NQR data for quality improvement were mainly assigned to three of the five CFIR domains. In the domain of intervention characteristics, data reliability and access in reasonable time were not considered entirely satisfactory, making it difficult for the politico-administrative leaderships to initiate, monitor, and support timely QI efforts. Still, politicians and administrators trusted the idea of using the NQRs as a base for quality improvement. In the domain of inner setting, the organizational structures were not sufficiently developed to utilize the advantages of the NQRs, and readiness for implementation appeared to be inadequate for two reasons. Firstly, the resources for data analysis and quality improvement were not considered sufficient at politico-administrative or clinical level. Secondly, deficiencies in leadership engagement at multiple levels were described and there was a lack of consensus on the politicians¿ role and level of involvement. Regarding the domain of outer setting, there was a lack of communication and cooperation between the county councils and the national NQR organizations.ConclusionsThe Swedish experiences show that a government-supported national system of well-funded, well-managed, and reputable national quality registries needs favorable local politico-administrative conditions to be used for quality improvement; such conditions are not yet in place according to local politicians and administrators.

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  • 5.
    Fredriksson, Mio
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Eldh, Ann Catrine
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Dahlström, Tobias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Wallin, Lars
    Dalarna Univ, Sch Educ Hlth & Social Studies, SE-79188 Falun, Sweden.;Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Nursing, Alfred Nobels Alle 23, SE-14183 Huddinge, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Dept Hlth & Care Sci, Box 100, SE-40530 Gothenburg, Sweden..
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Are data from national quality registries used in quality improvement at Swedish hospital clinics?2017In: International Journal for Quality in Health Care, ISSN 1353-4505, E-ISSN 1464-3677, Vol. 29, no 7, p. 909-915Article in journal (Refereed)
    Abstract [en]

    To investigate the use of data from national quality registries (NQRs) in local quality improvement as well as purported key factors for effective clinical use in Sweden. Comparative descriptive: a web survey of all Swedish hospitals participating in three NQRs with different levels of development (certification level). Heads of the clinics and physician(s) at clinics participating in the Swedish Stroke Register (Riksstroke), the Swedish National Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) and the Swedish Lung Cancer Registry (NLCR). Individual and unit level use of NQRs in local quality improvement, and perceptions on data quality, organizational conditions and user motivation. Riksstroke data were reported as most extensively used at individual and unit levels ((x) over bar 17.97 of 24 and (x) over bar 27.06 of 35). Data quality and usefulness was considered high for the two most developed NQRs ((x) over bar 19.86 for Riksstroke and (x) over bar 19.89 for GallRiks of 25). Organizational conditions were estimated at the same level for Riksstroke and GallRiks ((x) over bar 12.90 and (x) over bar 13.28 of 20) while the least developed registry, the NLCR, had lower estimates (x<overline> 10.32). In Riksstroke, the managers requested registry data more often ((x) over bar 15.17 of 20). While there were significant differences between registries in key factors such as management interest, use of NQR data in local quality improvement seems rather prevalent, at least for Riksstroke. The link between the registry's level of development and factors important for routinization of innovations such as NQRs needs investigation.

  • 6.
    Sanner, Margareta A.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Halford, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Röing, Marta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    The dilemma of patient safety work: Perceptions of hospital middle managers2018In: Journal of Healthcare Risk Management, E-ISSN 2040-0861, Vol. 38, no 2, p. 47-55Article in journal (Refereed)
    Abstract [en]

    Patient safety continues to be a challenge for health care. Medical errors are not decreasing but continue to show roughly the same patterns in Sweden and other Western countries. This interview study aims to explore how 27 hospital middle managers responsible for patient safety work in a Swedish university hospital perceive this task. A qualitative analysis was performed. A code template was created, and each code was explored in depth and summarized into six categories. We conclude that patient safety work appears to have low priority; hospital top management does not seem to have any real interest in patient safety; incidents are underreported; and the organization of patient safety work seems to be insufficient and carried out insofar as resources are available. These parameters may explain why medical errors remain on a certain level and do not seem to decrease in spite of various support programs.

  • 7.
    Vengberg, Sofie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Marketisation of Swedish Primary Care: Patient Choice, Provider Competition and Payment Incentives2022Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    In the last decades, market elements—such as patient choice, provider competition and payment incentives—have been introduced in Swedish primary care, the Patient Choice reform in 2010 being pivotal for the marketisation of the sector. The political intentions with the reform were to empower patients and increase provider diversity, thereby stimulating competition and improving quality and access. The reform embedded a more market-based governance of the sector; resource allocation and accountability being achieved on the basis of patient choices, and policy goals being attained through provider competition. For this to occur, several conditions on both the demand-side and supply-side must be fulfilled. Empirical evidence on market conditions are, however, especially lacking on the supply-side. The aim of this dissertation is therefore to investigate whether and how the Swedish primary care sector and its providers have adapted to the market elements of the Patient Choice reform. Three research questions are raised, addressing how providers perceive and respond to the different market elements, how competitive the sector is, and in what way the market elements promote achievement of central policy goals: quality, access and equity. To answer these questions, four studies are presented: two qualitative interview studies and two quantitative cross-sectional studies. Together, the studies demonstrate that providers are, in general, not very sensitive to patients’ choices and to competition. In the government bill preceding the Patient Choice reform, provider reimbursements were described as a way for money to follow patients’ choices, thereby sharpening the demand signals. Instead, findings indicate that reimbursements mainly are a tool for the regions to steer provider behaviours. The primary care market is also diverse in terms of competition. A large share of the primary healthcare centres is located in local monopoly markets, whereas those located in competitive markets often face rather stiff competition. Moreover, findings show a mixed picture on how market elements promote goals on quality, access and equity. Higher levels of competition are found in more urban local markets and in local markets with a population of higher socioeconomic status. Because competition is unequally distributed, so are conditions for competition to improve performance. Furthermore, providers describe how equity in access has been negatively affected by fee-for-service reimbursements. In summary, there are several obstacles on the supply-side of the Swedish primary care market for the market elements to function as intended in the Patient Choice reform, but also for promoting central policy goals.

    List of papers
    1. Patient choice and provider competition: Quality enhancing drivers in primary care?
    Open this publication in new window or tab >>Patient choice and provider competition: Quality enhancing drivers in primary care?
    2019 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 226, p. 217-224Article in journal (Refereed) Published
    Abstract [en]

    Patient choice of provider and provider competition have been introduced with the claim that they would lead to improved quality. For this to occur, certain conditions must be fulfilled on both the demand and the supply side. However, supply side-mechanisms – with provider behaviour as central – have been largely neglected in the literature, especially in primary care markets. In this article, we focus on provider behaviour and explore if and how choice and competition function as quality enhancing drivers in Swedish primary care. We explore this through semi-structured interviews with 24 managers and physicians at 13 Swedish primary healthcare centres, conducted from May 2016 to February 2017. The analysis draws on assumptions that for enhanced quality, providers must receive information on patients' choices, analyse it and respond accordingly. One conclusion is that Swedish primary care providers lack information on patients' choices and "exits", which makes it difficult for providers to respond to patients' choices. Furthermore, it is questionable whether choice and competition stimulate enhanced clinical quality. At the same time, choice and competition seems to make providers more aware of accessibility concerns and of their reputation, which they may be stimulated to improve. The article contributes evidence on supply side-mechanisms, and encourages clarification of "quality" in this respect, both on the political arena as well as in theoretical models.

    Keywords
    Sweden, Patient choice, Competition, Quasi-market, Primary care
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:uu:diva-379412 (URN)10.1016/j.socscimed.2019.01.042 (DOI)000466251700025 ()30878640 (PubMedID)
    Funder
    Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-4763
    Available from: 2019-03-15 Created: 2019-03-15 Last updated: 2022-10-31Bibliographically approved
    2. Money matters: primary care providers' perceptions of payment incentives
    Open this publication in new window or tab >>Money matters: primary care providers' perceptions of payment incentives
    Show others...
    2021 (English)In: Journal of Health Organization & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 35, no 4, p. 458-474Article in journal (Refereed) Published
    Abstract [en]

    Purpose Payments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work. Design/methodology/approach An interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system. Findings Findings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses. Practical implications Policymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers. Originality/value This study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.

    Place, publisher, year, edition, pages
    Emerald Group Publishing LimitedEmerald, 2021
    Keywords
    Primary care, Sweden, GPs, Incentives, Payments, Interview study
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:uu:diva-454197 (URN)10.1108/JHOM-06-2020-0225 (DOI)000614306600001 ()33522211 (PubMedID)
    Funder
    Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-4763
    Available from: 2021-09-28 Created: 2021-09-28 Last updated: 2024-01-15Bibliographically approved
    3. Measuring competition in primary care: Evidence from Sweden
    Open this publication in new window or tab >>Measuring competition in primary care: Evidence from Sweden
    (English)Manuscript (preprint) (Other academic)
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:uu:diva-487618 (URN)
    Available from: 2022-10-31 Created: 2022-10-31 Last updated: 2022-10-31
    4. Competition in Swedish primary care: An analysis of the socioeconomic and geographical distribution
    Open this publication in new window or tab >>Competition in Swedish primary care: An analysis of the socioeconomic and geographical distribution
    (English)Manuscript (preprint) (Other academic)
    National Category
    Health Care Service and Management, Health Policy and Services and Health Economy
    Identifiers
    urn:nbn:se:uu:diva-487617 (URN)
    Available from: 2022-10-31 Created: 2022-10-31 Last updated: 2022-10-31
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  • 8.
    Vengberg, Sofie
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Burstrom, Bo
    Karolinska Inst, Dept Global Publ Hlth, Stockholm, Sweden..
    Burstrom, Kristina
    Karolinska Inst, Dept Learning Informat Management & Eth, Stockholm, Sweden..
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Money matters: primary care providers' perceptions of payment incentives2021In: Journal of Health Organization & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 35, no 4, p. 458-474Article in journal (Refereed)
    Abstract [en]

    Purpose Payments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work. Design/methodology/approach An interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system. Findings Findings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses. Practical implications Policymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers. Originality/value This study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.

  • 9.
    Vengberg, Sofie
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Fredriksson, Mio
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Winblad, Ulrika
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
    Patient choice and provider competition: Quality enhancing drivers in primary care?2019In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 226, p. 217-224Article in journal (Refereed)
    Abstract [en]

    Patient choice of provider and provider competition have been introduced with the claim that they would lead to improved quality. For this to occur, certain conditions must be fulfilled on both the demand and the supply side. However, supply side-mechanisms – with provider behaviour as central – have been largely neglected in the literature, especially in primary care markets. In this article, we focus on provider behaviour and explore if and how choice and competition function as quality enhancing drivers in Swedish primary care. We explore this through semi-structured interviews with 24 managers and physicians at 13 Swedish primary healthcare centres, conducted from May 2016 to February 2017. The analysis draws on assumptions that for enhanced quality, providers must receive information on patients' choices, analyse it and respond accordingly. One conclusion is that Swedish primary care providers lack information on patients' choices and "exits", which makes it difficult for providers to respond to patients' choices. Furthermore, it is questionable whether choice and competition stimulate enhanced clinical quality. At the same time, choice and competition seems to make providers more aware of accessibility concerns and of their reputation, which they may be stimulated to improve. The article contributes evidence on supply side-mechanisms, and encourages clarification of "quality" in this respect, both on the political arena as well as in theoretical models.

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