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Despite universal measures in Sweden, the proportion of children living in economic hardship is increasing. One strategy to mitigate hardship is integrating financial counselling within healthcare services. This paper describes a pilot randomised controlled trial (RCT) of the ‘Healthier Wealthier Families’ model in which child healthcare nurses screen parents of young children for economic hardship and refer those in need to free budget and debt counselling (BDC). The study was an internal pilot of a two-arm randomised waitlist-control trial with a one-to-one allocation. The intervention arm received BDC immediately after randomisation, while the waitlist-control arm was referred 3 months later. Both arms received a financial guidance book. Assessments were conducted at two points: pre-intervention (T1) and post-intervention (T2; 3 months post-randomisation). The main objective was to assess the feasibility of recruitment, randomisation, data collection, attendance, and adherence to the topic guide. Of 368 screened parents, 111 (30.2%) were eligible, most of whom were identified by two of the five screening questions focused on ‘worrying about running out of money’ and ‘meeting an unexpected cost’. The conversion rate from screening positive to consenting for trial was 18.0% (n=20). Reasons for declining were due to stigma, lack of capacity or already available knowledge and support. The randomisation was effective, with equal distribution between trial arms. No contamination was detected. Eight out of ten participants who were allocated to the intervention attended at least one session; the mean number of sessions was two. Topic guide implementation was inconsistent. There were high completion rates for most measures, except for income. The primary outcome measure of Child Material and Social Deprivation showed a floor effect, with many parents reporting zero ‘enforced lack’ items. Results from the pilot RCT indicate that the screening process identified the anticipated proportion of eligible parents (30.2%), but that three of the screening questions are redundant. The conversion rate was much lower than anticipated, questioning the feasibility of a full-scale RCT. BDC fidelity to protocol could be strengthened with implementation support. Finally, the primary outcome measure should be reconsidered, as well as the way in which participant income is captured. 

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.

Introduction

In many tax-based healthcare systems, policymakers have introduced reforms that promote provider competition with the intention of improving the quality and efficiency. Healthcare competition is usually defined spatially, with local markets often being identified as a circle around each provider. We argue that existing local market definitions can be improved to better capture actual local markets. For pro-competition reforms to potentially lead to the gains envisioned by policymakers, a crucial condition is the actual emergence of competitive markets. However, limited research has been conducted on competition in primary care markets, despite primary care constituting a vital part of a healthcare system.

Aim

The study aims to contribute to the debate on how to define local markets geographically and to examine provider competition in Swedish primary care.

Methods

A cross-sectional study was conducted using data on all individuals and all primary care providers in Sweden. Local markets were defined as: fixed radius (1 km and 3 km); variable radius; and variable shape—our new local market definition that allows markets to vary in both size and shape. Competition was measured using the Herfindahl-Hirschman index and a count of the number of competitors within the local market.

Results

Fixed radius markets fail to capture variation within and across geographical areas. The variable radius and variable shape markets are similar but do not always identify the same competitors or level of competition. Furthermore, competition levels vary significantly in Swedish primary care. Many providers operate in monopoly markets, whereas others face high competition.

Conclusions

While the variable shape approach has the potential to better capture actual markets and more accurately identify competitors, further analyses are needed. Moreover, Swedish policymakers are advised to decide whether to still pursue competition and if so, take measures to improve local market conditions in monopolies.

Even for successfully implemented programs, there is a great risk that new work practices are not sustained over time. Previous research has yielded a number of factors which influence program sustainability, but little is known about which factors are most important in different contexts or how these factors interact. This study tests a model of sustainability factors in a case where a program for structured needs assessment and documentation was implemented in the Swedish social services. In November 2020, a questionnaire was sent out to local implementing actors in the municipalities. The data include 135 municipal organizations with 1–3 respondents per organization. Descriptive statistics and multiple regression were used in the analysis. The outcome variable was routinization as one of the most central components of sustainability. The findings show that while the program was implemented at 21.5% of sites, it was both implemented and routinized at only 13.3% of sites. A key factor for successful routinization was an open project strategy, which entails coordination between the implementation process and other change initiatives, the identification of a long-term planning horizon, and development based on continuous feedback. Additional factors found to contribute to routinization were management commitment, user participation, first-line manager commitment, and available resources. Certain factors were identified as pertinent to the implementing actors themselves, such as effective project leadership and rationally planned projects. These latter factors, however, demonstrated less importance towards routinization. These findings are discussed in relation to the fragmented context of the implementation, whereby the recipient organizations were not single, unified organizations, but rather organizational clusters involving both purchaser and provider organizations. The findings have implications for the planning, management, and evaluation of social program implementation and the ability to sustain novel work practices.

Background

Sweden is often held up as an example of a country with low child deprivation; yet, rates of relative deprivation are rising. Every municipality in Sweden is required to provide free, timely and accessible budget and debt counselling under the Social Services Act. The services have been encouraged to perform preventative practice with families; however, this has not been realised. The Healthier Wealthier Families (HWF) model embeds universal screening for economic hardship into child health services and creates a referral pathway to economic support services. Given the universal child health system in Sweden, which is freely available and has excellent coverage of the child population, implementation of the HWF model has potential to support families to access the freely available municipal budget and debt counselling and ultimately improve rates of child deprivation in Sweden.

Methods/design

We will conduct a two-arm randomised waitlist-control superiority trial to examine the effectiveness and cost-effectiveness of the HWF model in the Sweden. A longitudinal follow-up with the cohort will explore whether any effects are maintained in the longer-term.

Discussion

HWF is a collaborative and sustainable model that could maximise the effectiveness of current services to address child deprivation in Sweden. The study outlined in this protocol is the first effectiveness evaluation of the HWF model in Sweden and is a crucial step before HWF can be recommended for national implementation within the child health services.

Background: In 2007, a reform of Swedish primary healthcare began when some regions implemented enhanced patient choice in combination with free establishment for private providers. Although heavily debated, in 2010 it became mandatory for all regions to implement this choice system.

Aim: The aim of this article was to review all published research articles related to the primary healthcare choice reform in Sweden, to investigate what has been published about the reform and summarise its first 15 years.

Methods: A scoping review was performed to cover the breadth of research on the reform. Searches were made in Scopus, Web of Science and PubMed for articles published between 2007 and 2021, resulting in 217 unique articles. In total, 52 articles were included. Results: The articles were summarised and presented in relation to six overarching themes: arguments about the primary healthcare choice reform; governance and financial reimbursements; choice of provider and use of information; effects on equity and access; effects on quality; and differences between private and public primary healthcare centres.

Conclusions: The articles show that the reform has led to an increase in access to primary healthcare, but most studies indicate that the increase is inequitably distributed in terms of socioeconomy and geographical location. The effects on quality are unclear but several studies show that the mechanisms supposed to lead to quality improvements do not work as intended. Furthermore, from a population health perspective, it is time to discuss how such a responsibility can be reintegrated into primary healthcare and function with the choice system.

Background: Patient registration with a primary care providers supports continuity in the patient provider relationship. This paper develops a framework for analysing the characteristics of patient registration across countries; applies this framework to a selection of countries; and identifies challenges and ongoing reform efforts.

Methods: 12 jurisdictions (Denmark, France, Germany, Ireland, Israel, Italy, Netherlands, Norway, Ontario [Canada], Sweden, Switzerland, United Kingdom) were selected for analysis. Information was collected by national researchers who reviewed relevant literature and policy documents to report on the establishment and evolution of patient registration, the requirements and benefits for patients, providers and payers, and its connection to primary care reforms.

Results: Patient registration emerged as part of major macro-level health reforms linked to the introduction of universal health coverage. Recent reforms introduced registration with the aim of improving quality through better coordination and efficiency through reductions in unnecessary referrals. Patient registration is mandatory only in three countries. Several countries achieve high levels of registration by using strong incentives for patients and physicians (capitation payments).

Conclusion: Patient registration means different things in different countries and policy-makers and researchers need to take into consideration: the history and characteristics of the registration system; the use of incentives for patients and providers; and the potential for more explicit use of patient-provider agreements as a policy to achieve more timely, appropriate, continuous and integrated care.

A primary care choice reform launched in Sweden in 2010 led to a rapid growth of private providers. Critics feared that the reform would lead to an increased tendency among new, profit-driven, providers, to select patients with lower health risks. Even if open risk selection is prohibited, providers can select patients in more subtle ways, such as establishing their practices in areas with higher health status. This paper investigates to what extent strategies were employed by local governments to avoid risk selection and whether there were any differences between left- and right-wing governments in this regard. Three main strategies were used: risk adjustment of the financial reimbursements on the basis of health and/or socio-economic status of listed patients; design of patient listing systems; and regulatory requirements regarding the scope and content of the services that had to be offered by all providers. Additionally, left-wing local governments were more prone than right-wing governments to adopt risk adjustment strategies at the onset of the reform but these differences diminished over time. The findings of the paper contribute to our understanding of how social inequalities may be avoided in tax-based health care systems when market-like steering models such as patient choice are introduced.

When contracting out services to private actors, public authorities must be able to ensure that the quality of services provided is satisfactory. Therefore, it is important to formulate precise quality requirements, thus making them possible to monitor. In the study, 1,005 quality requirements from public procurements of nursing homes were categorized, and their degree of monitorability assessed. The analysis showed that quality requirements related to soft' areas such as social activities typically were non-monitorable. The requirements were written in an imprecise, vague manner, thus making it difficult for the local governments to determine whether or not they were met.