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Background: Priority-setting models have the potential to enhance transparency and support decision-making under conditions of resource scarcity; however, their practical application remains limited, particularly in large-scale decommissioning programmes. This article examines department managers' perceptions of using a National Model for Transparent Prioritization (NMTP) at their clinics during the implementation of a decommissioning programme. In addition, the study explores whether the model contributes to fair priority setting and to procedural and substantive legitimacy.

Methods: A convergent mixed-methods design was employed, integrating quantitative and qualitative data from a survey (n = 33) and semi-structured interviews (n = 22). The analysis addressed six questions grouped into two overarching themes: (1) the model's use and contribution (adoption, exclusion, and inclusion of care) and (2) the model's legitimacy (acceptance, justification, and fairness of priorities).

Results: Department managers expressed varying perceptions of the NMTP. Approximately half of them considered the time and resources required to be justified and perceived that the model ensured patients with the greatest needs were given the highest priority. About one third agreed that the NMTP was accepted as a tool for prioritization and resource allocation, and a similar proportion reported that the NMTP had been used to exclude care that was previously provided.

Conclusions: Department managers perceived that the NMTP facilitated the application of the Swedish ethical guidelines; however, they also identified several challenges associated with its use in the context of a large-scale decommissioning programme, including time constraints, a substantial initial threshold, demanding evidence requirements, and insufficient alignment with national objectives. Furthermore, resistance encountered within clinical units may have been attributable to limited stakeholder engagement.

Personal assistance (PA) in Sweden, regulated by the Act concerning support and service for persons with certain functional impairments, aligns with the Convention on the Rights of Persons with Disabilities. This paper explores the facilitators and barriers impacting the access to PA in Sweden. A thematic analysis of 15 interviews was conducted with public officials at the Swedish Social Insurance Agency, who develop and manage the PA-allowance granting process. A medicalised application of this granting process was revealed due to external and internal factors, i.e. legal changes in the Act, caselaw, PA service marketisation, shifting policy priorities, and inadequate monitoring of PA, a high complexity of the PA-allowance granting process and organizational pressure on the officials. A medicalised policy application of the PA-allowance granting criteria risks undermining disability rights policy goals. The paper emphasizes the importance of follow-ups to maintain calibration and understanding of policy outcomes over time.

This article investigates how the institutional conditions of multi-level contexts are accommodated in central-local governance by analyzing policy agreements in the Swedish healthcare sector. These policy agreements have developed in recent decades, and are today an instrument mix that constitutes a new way for the national government to govern the decentralized healthcare sector. In the study, this new instrument mix is related to the decentralized unitary context of Sweden by investigating how steering and cooperation are combined in the formulation and composition of three policy agreements. The results show how adaptable steering is made possible by opportunities for continuous communication and a shared administrative structure between regional and national actors. Furthermore, through flexibility in the roles of involved actors, particularly the national government, the policy agreements allow for consensus-making and a sense of togetherness between governmental levels. Arguably, this shows how instrument mixes can accommodate steering and cooperation in ways that can be important for central-local governance in the future. Also, the study relates to recent scholarly work on the relation between governmental levels in unitary contexts which, until recently, has been largely neglected.

Background

At emergency medical dispatch centres (EMDCs) telephone triage takes place in three steps: identifying the event, assessing the callers' need for support, and prioritizing the response. Some calls are considered to be more difficult to handle than others, and decision support systems may in these situations be of limited help. The aim of this study was to describe and characterize difficult calls to EMDCs.

Methods

Retrospective call data from 2022 to 2023 was extracted for Registered Nurse (RN) dispatchers at three EMDCs in Sweden agreeing to participate in this mixed-method study. Categories of difficult calls were identified based on prior research and operationalized as key-word searches in the free text call notes or as indicators based on structured data. A purposeful selection of calls meeting these criteria were extracted, anonymized, and data regarding categories and the phase on the call in which they occurred then coded. A descriptive quantitative analysis was performed, and logistic regression was used to estimate the association between demographics and the likelihood of high-priority ambulance dispatch.

Results

Over the two-year study period, 14 included RNs handled 27,805 calls. Of these, 4888 calls (17.6%) were identified as potentially difficult calls based on free-text notes and structured data, from which 123 calls were selected for further analysis. The median age of callers were 49 years, and 49% were female. Median call duration was 5.6 min, compared to 5.1 min in the full dataset, and 39.5% of calls resulted in a lights and sirens response.Vague or unclear symptoms and psychiatric problems were the most common difficulties. These could occur in all three phases of the calls and in several of the phases in one single call, with a combination of "assessing and prioritizing" being the most common. Male sex was found to be associated with a higher likelihood of receiving an ambulance with high priority.

Conclusions

Difficult calls, mainly with vague or unclear symptoms and psychiatric problems, are common at EMDCs. The reason for the tendency to prioritize young males higher are seen in other contexts but not in truly high priority cases at dispatch and needs further investigation.

The increasing prevalence of private health insurance (PHI) in tax-funded healthcare systems challenges the principles of equity and universalism. A significant proportion of PHI holders in such systems receive their insurance as an employment benefit, granting them access to privately funded healthcare alongside the publicly funded system. This dual access raises critical questions about how individuals navigate between the two sectors and how their experiences shape their perceptions of public healthcare. The aim of this study is to explore how the use of PHI-funded healthcare services influences perceptions of and satisfaction with the public healthcare system. Specifically, we examine when PHI holders choose privately funded care over public services, how they perceive the two sectors, and whether they would purchase PHI independently if it were not offered as an employment benefit. An interview study was conducted in 2022 with 19 individuals in Sweden who receive PHI as an employment benefit. Using thematic analysis, the findings reveal a preference for privately funded services due to faster access and higher service quality. However, the medical quality of specialised care in the public sector is still regarded as high. PHI is perceived as providing a sense of security through prompt care, but few respondents expressed a willingness to purchase it privately, suggesting it is seen more as a convenience than a necessity. These findings highlight the role of PHI in shaping expectations and satisfaction within tax-funded healthcare systems, offering insights into its potential impact on public trust and support of universal healthcare.

Introduction: Health and social care systems are constantly undergoing major reforms to meet the rising demands of an increasing proportion of older patients, with many such reforms aiming to improve integration and coordination. The aim of this systematic review was to synthesize the evidence on inter-organizational coordination interventions between hospitals and outpatient (health- and social care) providers for older patients with complex needs during- and after hospital discharge.

Methods: A systematic search of four databases was performed to identify interventions of inter-organizational coordination at hospital discharge for older patients with complex needs. The retrieved literature was analyzed using a narrative synthesis.

Results: Twelve studies were included (seven randomized controlled trials and five non-randomized intervention studies). The most common intervention components were; needs assessments, dedicated care coordinators and multi-professional teams. Findings show that inter-organizational coordination could decrease- or even increase readmission rates, with similar findings for hospital length of stay and mortality. Furthermore, inter-organizational coordination seemed to have a positive impact on quality of life and activities of daily living.

Conclusion: Inter-organizational coordination could potentially reduce health-care utilization and improve quality of life for older patients with complex needs. However, the findings remain uncertain and further research is warranted.

Background: Mental ill-health has increased among young people in Sweden in recent years, particularly among young women. One contributing factor could be a striving for high social status, communicated around the clock on social media platforms. The aim of the study was to explore how young working women in Sweden perceive social status and how it relates to their own health and well-being.

Methods: The study sample included 15 women aged 25–35 years, recruited from the Swedish Longitudinal Occupational Survey of Health, a cohort derived from a representative sample of the Swedish working population. Maximum variation purposeful sampling was employed to achieve rich information in the data. Data were collected through individual semi-structured interviews and analysed using thematic analysis.

Results: The analysis identified two main themes. The first theme, the qualities and processes of subjective social status, consisted of the subthemes material and personal resources and interpersonal and contextual interplay, and described aspects affecting social status, such as income, gender, and social life, as well as processes such as external influence and comparison. The second theme, the influence of subjective social status on health and well-being consisted of the subthemes being judged by oneself and others and strategies to reduce negative impact, and encompassed emotional responses to social status and approaches and attitudes to regulate its impact.

Conclusions: The results indicate that subjective social status in young working women today is established through dynamic and interactive processes involving several important aspects beyond traditional socioeconomic measures. The findings regarding the impact of gender and foreign background on subjective social status suggest a need for continued efforts to strengthen equality and integration in Swedish society. The impact of processes around establishing and displaying subjective social status on well-being and health appears to vary, depending on each individual's approach and active management of, e.g., social media.

Background: In Sweden, healthcare provision for the frail elderly entails coordination between municipalities and regions. Despite formal agreements, deficiencies persist in achieving practical coordination, leading to adverse effects on patients and increased costs. The Covid-19 pandemic further strained the health- and social care system, exposing shortcomings in eldercare coordination. This paper explores the impact of crises on inter-organizational coordination between long-term organizational collaborators, operationalized through medical care coordination in Swedish nursing homes during the Covid-19 pandemic.

Methods: The study examines coordination between regionally employed physicians and municipal nursing home nurses through a mixed methods approach. A survey was sent to regional physicians and municipal nurses working in eldercare, as well as managers at both nursing homes and healthcare centers. A total of 170 responded to the survey, and 20 participants took part in a subsequent follow-up interview.

Results: Findings indicate that medical care coordination was perceived to have functioned relatively well during the pandemic and even to have improved afterward. Key factors contributing to this outcome include the adoption of innovative solutions, such as digital technologies, to address both staff shortages and increased demand brought on by the crisis. Trust and shared cultural values among staff fostered collaboration, while personal engagement became crucial when compatibility was lacking. The respondents also highlighted improved communication channels and enhanced coordination as a means to combat uncertainties during the crisis.

Conclusions: The perception of well-functioning crisis coordination among the respondents contrasts with more critical views in general society. This discrepancy might be attributed to different expectations during crises; healthcare professionals adhere to specified standards, values, and beliefs within their specialized cultures. Healthcare professionals might therefore have a more nuanced perception of what they believe constitutes good medical care coordination. The contributions of this study include integrating the crisis management literature with inter-organizational coordination in healthcare. The approach provides new insights to clarify the impact of crises on medical care coordination and identify important factors regarding inter-organizational coordination during crises.

Background

Heart failure patients tend to experience higher rates of hospital readmissions compared to other ambulatory care-sensitive conditions. In Sweden, the nationwide Care Coordination Act (CCA) was introduced in January 2018 with the goal of improving care coordination resulting in a reduction of readmissions and length of stay. There is insufficient knowledge regarding the effect of this reform on heart failure patients.

Methods

We studied the association of implementing CCA on all cause 30-day readmissions and length of stay for patients over 65 years of age with ICD-50 heart failure. The dataset included all admissions with a primary diagnosis of heart failure among elderly, multimorbid patients between 2015 and 2019. An interrupted time series analysis using hierarchical mixed models with random effects clustered at the hospital ward level was conducted.

Results

A total of 111 414 admissions were included. The average readmission rate for heart failure patients was 26.8 % before and 26.7 % after the CCA. The average length of stay (LOS) was 8.4 days before the CCA and 8.1 days after. Mortality within 30 days was 7.3 % before the CCA and 7.5 % after. There were no significant differences between the periods before and after. In an analysis assessing the overall linear time trend 2 of 21 regions showed a reduction in readmissions and 10 in length of stay.

Conclusions

After the introducing the CCA, no detectable impact was found on readmissions or mortality for heart failure patients, which is in line with previous studies such as those studying the US Hospital Readmission Reduction Program. While no overall association on length of stay could be identified, it was reduced in a number of the Swedish regions. The heterogeneity between regions could be used to understand the specific components needed to achieve reduction of readmissions in future studies.

Background

Nursing homes have limited capacity to provide medical care to clinically frail residents and therefore rely on transferring residents to hospital-based emergency departments when acute medical needs arise. The utilization of emergency department care varies between nursing homes but the extent of this variation is unexplored. Further, the effect of organizational characteristics of nursing homes on emergency department utilization is unknown. This study aims to characterize the variation in emergency department visit rates between nursing homes, and to identify contextual and organizational characteristics that contribute to this variation.

Study design

Population-based cohort study of individuals living in nursing homes during 2019 and 2020 in Sweden.

Methods

National registry data on nursing home residents were linked to nursing homes based on civil- and business registration addresses. Emergency department visits were identified for each resident in the national patient registry and measured as incidence rates per nursing home. Multi-level analysis was performed to investigate the association between emergency department visit rates, and contextual and organizational characteristics of nursing homes.

Results

The median incidence rate of emergency department visits from nursing homes was 5.2 per 100 person-months in 2019 (IQR = 3.7–6.9) and 4.4 per 100 person-months in 2020 (IQR = 3.0–5.7). Individuals living in nursing homes in the most rural locations had lower odds of emergency department visits (OR 0.51, 95% CI 0.41–0.61 versus the most urban locations). Moreover, individuals in nursing homes specialized in dementia care had lower odds of emergency department visits (OR 0.90, 95% CI 0.87–0.94 versus somatic care).

Conclusion

The results suggest that the location and organizational characteristics of nursing homes may have an impact on the utilization of medical services by the nursing home resident population. Further research is warranted to investigate any ensuing health inequities.