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This paper explores and compares health system responses to the COVID-19 pandemic in Denmark, Finland, Iceland, Norway and Sweden, in the context of existing governance features. Content compiled in the Covid-19 Health System Response Monitor combined with other publicly available country information serve as the foundation for this analysis. The analysis mainly covers early response until August 2020, but includes some key policy and epidemiological developments up until December 2020. Our findings suggest that despite the many similarities in adopted policy measures, the five countries display differences in implementation as well as outcomes. Declaration of state of emergency has differed in the Nordic region, whereas the emphasis on specialist advisory agencies in the decision-making process is a common feature. There may be differences in how respective populations complied with the recommended measures, and we suggest that other structural and circumstantial factors may have an important role in variations in outcomes across the Nordic countries. The high incidence rates among migrant populations and temporary migrant workers, as well as differences in working conditions are important factors to explore further. An important question for future research is how the COVID-19 epidemic will influence legislation and key principles of governance in the Nordic countries. publishedVersion

This study explores important considerations from a patient perspective in decisions regarding centralisation of specialised health care services. The analysis is performed in the framework of the Swedish National Board of Health and Welfare's ongoing work to evaluate and, if appropriate, centralise low volume, highly specialised, health services defined as National Specialised Medical Care. In addition to a literature review, a survey directed to members of patient associations and semi-structured interviews with patient association representatives and health care decision makers were conducted. The results showed that from a patient perspective, quality of care in terms of treatment outcomes is the most important factor in decisions regarding centralisation of low volume, highly specialised health care. The study also indicates that additional factors such as continuity of treatment and a well-functioning care pathway are highly important for patients. However, some of these factors may be dependent on the implementation process and predicting how they will evolve in case of centralisation will be difficult. Patient engagement and patient association involvement in the centralisation process is likely to be a key component in attaining patient focused care and ensuring patient satisfaction with the centralisation decisions.

The literature suggests that triptans are cost effective compared with older types of migraine treatment. However, which of the triptans that is most cost effective has not been established. We compared the costs and effects of triptan treatment from a Swedish societal perspective, using evidence from the literature. A probabilistic cost-effectiveness model was constructed to investigate the costs and effects of treating a single attack in a typical migraine patient. The end-point used in the base-case analysis was sustained pain free without any adverse events (SNAE). We searched the scientific literature for meta-analyses reporting the efficacy of oral triptans. All treatments except rizatriptan 10 mg and eletriptan 40 mg were dominated. The incremental cost per SNAE of rizatriptan 10 mg compared with eletriptan 40 mg was approximately €100. There was substantial uncertainty concerning the results, but probabilistic analysis showed that rizatriptan 10 mg and eletriptan 40 mg had the highest probability of being cost-effective.

Periodontal scaling procedures commonly require some kind of anesthesia. From the patient's perspective, the choice of anesthetic method is a trade-off between the degree of anesthesia and accepting the side effects. The present study evaluates the preferences for a novel non-injection anesthetic product (a gel, containing lidocaine 25 mg/g plus prilocaine 25 mg/g and thermosetting agents) versus injection anesthesia (lidocaine 2% adrenaline) in conjunction with scaling and/or root planing (SRP).In a multicenter, crossover, randomized, open study patients were asked, after they had experienced both products, if they preferred anesthetic gel or injection anesthesia. In addition, the adequacy of anesthesia and occurrence of post-procedure problems were assessed. The patients were also asked about their willingness to return if they were offered anesthetic gel at their next visit and their maximum willingness to pay (WTP) for this option.One-hundred seventy (170) patients at eight centers in Belgium were included in the study. There were 157 per protocol (PP) patients. A vast majority of the PP patients (70%) preferred the anesthetic gel to injection anesthesia (22%). The most common reason was less post-procedure numbness. Eighty percent (80%) of the patients expressed satisfactory anesthesia with the gel and 96% with injection anesthesia (P0.001). Post-procedure problems were significantly less with the gel than with injection (P0.001): numbness 15% versus 66%, unpleasant sensations such as soreness and pain 44% versus 63%, and problems connected with daily activities 19% versus 69%. The majority of patients (60%) who preferred gel were also willing to pay for it. A conservative estimate of the median WTP was $10.00. Furthermore, anesthetic gel would make almost every second patient (45%) more or much more willing to return for the next treatment.The data suggest that a somewhat less profound anesthesia with gel is clearly preferred by the patients because of the low incidence of post-procedure problems as compared to conventional injection anesthesia. The median WTP is likely in excess of the acquisition cost of the product, which indicates a favorable cost-benefit ratio for the individual patient.

Huge variations in expenditure per life saved have been documented in the USA, Sweden, and Japan. Using an original-position argument, this paper examines normative rationales that might permit departures from equalization of marginal lifesaving investments. The conclusion is that adjustment for identifiability, as reflected in strict benefit-cost analysis, is not justified yet adjustments for consideration of longevity, quality of life and productivity are compelling. It is less clear as to whether factors such as ability to pay, voluntariness and catastrophic potential should influence lifesaving expenditures.

Results Embedded pragmatic clinical trials (PCTs) are set in routine health care, have broad eligibility criteria, and use routinely collected electronic data. Many consider them a breakthrough innovation in clinical research and a necessary step in clinical trial development. To identify barriers and success factors, we reviewed published embedded PCTs and interviewed 30 researchers and clinical leaders in 7 US delivery systems. Literature We searched PubMed, the Cochrane library, and clinicaltrials.gov for studies reporting embedded PCTs. We identified 108 embedded PCTs published in the last 10 years. The included studies had a median of 5540 randomized patients, addressed a variety of diseases, and practice settings covering a broad range of interventions. Eighty‐one used cluster randomization. The median cost per patient was $97 in the 64 trials for which it was possible to obtain cost data. Interviews Delivery systems required research studies to align with operational priorities, existing information technology capabilities, and standard quality improvement procedures. Barriers that were identified included research governance, requirements for processes that were incompatible with clinical operations, and unrecoverable costs. Conclusions Embedding PCTs in delivery systems can provide generalizable knowledge that is directly applicable to practice settings at much lower cost than conventional trials. Successful embedding trials require accommodating delivery systems' needs and priorities.

Although the need to safeguard the confidentiality of patients whose data might be shared is widely recognized, the authors discuss the similar need to consider the risks to health care systems and...

Large disparities in the cost per life saved for different lifesaving interventions have been reported in many studies. According to some researchers, these differences reflect the public's preoccupation with selected qualitative aspects of risk. However, it is not obvious that these disparities reflect public preferences. In studies of the variation in cost per life saved the public accepts, most respondents are willing to trade qualitative characteristics for lives saved, but there is a small but significant group of respondents who will not make the tradeoff, i.e. assign infinite value to one or more of the qualitative factors. It has been suggested that this group could be particularly vocal, which might account for the large variation in cost per life saved. In the first attempt to address this issue, a survey of people living under a power line in Stockholm was undertaken. This population was chosen because the local government had decided to remove the power line after being pressured by the citize...

In this article, we discuss under what conditions an estimated cost per statistical life saved can be interpreted as an implied lifevalue. Furthermore, we state optimality conditions with respect to variation in implied lifevalues. The cost-effectiveness, together with references, are presented for 165 lifesaving interventions in Sweden. The cost-effectiveness of interventions has been found in publicly available analyses, or in some cases been calculated by us. Several of these interventions produce net savings for society. The most expensive interventions cost several hundred million SEK, or more, per life saved. To improve the comparability of the interventions, certain criteria have been used to standardize the estimates. Still, dissimilarities in the calculation of implied life values remain and the quality of the original data is in some cases uncertain. Despite this and the fact that the interventions are not a representative sample, it is nevertheless possible to conclude that implied life values vary greatly both within and between different sectors of the Swedish society, much in the same manner as in current U.S. analyses.

Sharing data from cluster-randomized trials may be difficult. Hundreds of thousands of patients may be involved, and health systems and providers are subjects of the research. A solution may be to give researchers access to datasets without allowing possession of the data.

Basing drug reimbursement on cost-effectiveness provides too little incentives for R&D. The reason for this is that cost-effectiveness is concerned with immediate value for money. But since the price of a drug usually declines over time, the drug might well provide value for money as seen over its entire life cycle, even though its price during patent protection is too high to warrant reimbursement according to the cost-effectiveness decision rule. We show in a theoretical model that welfare could be improved if decision-makers took a longer perspective and initially allowed higher prices than immediate value for money can motivate. We also discuss the real world relevance of applying dynamic cost-effectiveness.

This study assessed the quality of health economic documentation submitted to the Pharmaceutical Benefits Board (PBB) in Sweden. Two different instruments were used in the evaluation: the PBB checklist, which was constructed by the authors from the PBB guidelines for health economic evaluations, and the QHES, a validated quality assessment instrument. Some areas that seem especially problematic, or where the quality was particularly low are identified and discussed. Also, we present the cost per quality-adjusted life-year that the companies have presented and how this related to the PBBs decisions.

Objective A randomised controlled study performed from 2007 to 2008 showed beneficial effects of a composite clinical pharmacist service as regards a simple health status instrument. The present study aimed to evaluate if the intervention was cost-effective when evaluated in a decision-theoretic model. Design A piggyback cost-effectiveness analysis from the healthcare perspective. Setting Two internal medicine wards at Sahlgrenska University Hospital, Göteborg, Sweden. Participants Of 345 patients (61% women; median age: 82 years; 181 control and 164 intervention patients), 240 patients (62% women, 82 years; 124 control and 116 intervention patients) had EuroQol-5 dimensions (EQ-5D) utility scores at baseline and at 6-month follow-up. Outcome measures Costs during a 6-month follow-up period in all patients and incremental cost-effectiveness ratio per quality-adjusted life-year (QALY) in patients with EQ-5D utility scores. Inpatient and outpatient care was extracted from the VEGA database. Drug costs were extracted from the Swedish Prescribed Drug Register. A probabilistic analysis was performed to characterise uncertainty in the cost-effectiveness model. Results No significant difference in costs between the randomisation groups was found; the mean total costs per individual±SD, intervention costs included, were €10 748±13 799 (intervention patients) and €10 344±14 728 (control patients) (p=0.79). For patients in the cost-effectiveness analysis, the corresponding costs were €10 912±13 999 and €9290±12 885. Intervention patients gained an additional 0.0051 QALYs (unadjusted) and 0.0035 QALYs (adjusted for baseline EQ-5D utility score). These figures result in an incremental cost-effectiveness ratio of €316 243 per unadjusted QALY and €463 371 per adjusted QALY. The probabilistic uncertainty analysis revealed that, at a willingness-to-pay of €50 000/QALY, the probability that the intervention was cost-effective was approximately 0.2. Conclusions The present study reveals that an intervention designed like this one is probably not cost-effective. The study thus illustrates that the complexity of healthcare requires thorough health economics evaluations rather than simplistic interpretation of data., Article summary Article focus Clinical pharmacist services have been shown beneficial for patient health and healthcare costs, although results are inconsistent. In the present article, we present combined data on costs and health outcomes for a composite clinical pharmacist service. Key messages Although our composite clinical pharmacist service has previously been shown beneficial as regards a simple health status instrument, the incremental cost-effectiveness ratio per QALY was high, more than €460 000 in the base case and more than €100 000 in most sensitivity analyses. Strengths and limitations of this study This study is the first one to provide data on costs per QALY for an in-hospital intervention aimed to improve drug treatment. An important limitation may be that the pharmacists acted like external consultants rather than an integrated part in healthcare, and further research on cost-effectiveness of pharmacist services may be called for.

Background Offering patients in oncology trials the opportunity to cross over to active treatment at disease progression is a common strategy to address ethical issues associated with placebo controls but may lead to statistical challenges in the analysis of overall survival and cost-effectiveness because crossover leads to information loss and dilution of comparative clinical efficacy. Objectives We provide an overview of how to address crossover, implications for risk-effect estimates of survival (hazard ratios) and cost-effectiveness, and how this influences decisions of reimbursement agencies. Two case studies using data from two phase III sunitinib oncology trials are used as illustration. Methods We reviewed the literature on statistical methods for adjusting for crossover and recent health technology assessment decisions in oncology. Results We show that for a trial with a high proportion of crossover from the control arm to the investigational arm, the choice of the statistical method greatly affects treatment-effect estimates and cost-effectiveness because the range of relative mortality risk for active treatment versus control is broad. With relatively frequent crossover, one should consider either the inverse probability of censoring weighting or the rank-preserving structural failure time model to minimize potential bias, with choice dependent on crossover characteristics, trial size, and available data. A large proportion of crossover favors the rank-preserving structural failure time model, while large sample size and abundant information about confounding factors favors the inverse probability of censoring weighting model. When crossover is very infrequent, methods yield similar results. Conclusions Failure to correct for crossover may lead to suboptimal decisions by pricing and reimbursement authorities, thereby limiting an effective drug's potential.

In the context of pharmaceutical care, policy-makers repeatedly face the challenge of balancing patient access to effective medicines with affordability and rising costs. With the aim of guiding the health policy discourse towards questions that are important to actual and potential patients, this study investigates a broad range of regulatory measures, spanning marketing authorization to generic substitution and resulting price levels in a sample of 16 European health systems (Austria, Belgium, Denmark, England, Finland, France, Germany, Greece, Ireland, Italy, the Netherlands, Poland, Portugal, Scotland, Spain and Sweden). All countries employ a mix of regulatory mechanisms to contain pharmaceutical expenditure and ensure quality and efficiency in pharmaceutical care, albeit with varying configurations and rigour. This variation also influences the extent of publicly financed pharmaceutical costs. Overall, observed differences in pharmaceutical expenditure should be interpreted in conjunction with the differing volume and composition of consumption and price levels, as well as dispensation practices and their impact on measurement of pharmaceutical costs. No definitive evidence has yet been produced on the effects of different cost-containment measures on patient outcomes. Depending on the foremost policy concerns in each country, different levers will have to be used to enable the delivery of appropriate care at affordable prices.