The GPs and nurses found the key priority-setting criteria to be useful, reporting that these criteria made them think in a new way when prioritising. One GP said:
"What's new, it's these two - patient benefit and cost-effectiveness. We always thought about severity. But we didn't consider so much whether the patient would actually benefit from coming here."(GP 3, Group 3)
They described how using the key priority-setting criteria stimulated them to consider carefully the value that an intervention actually had for the patient:
"I think this is more appropriate. Without this, my impression of a consultation plays a major role: 'How was the contact? What actions did I take?' This way is more systematic: 'The disease is diabetes. It's a serious disease that needs to be managed properly even if really I don't do much more than find that it looks pretty decent and renew prescriptions.' When I adjust my subjective impression of not doing so much, so much effort, it is adjusted in a more systematic way." (GP 3, Group 4)
The staff were more detailed in discussions concerning the severity of the health condition and patient benefit than they were about cost-effectiveness. Most reported difficulty in applying the cost-effectiveness concept. Some staff members did not want to think about the costs of health care at all.
"It's terrible to say, but this thinking about economy ... even if I know ... What we learned was nursing, to take care of patients and diseases. And I am supposed to think about cost-effectiveness and health benefits and .... No, this is difficult." (Nurse 2, Group 8)
In spite of the difficulties in applying the concept of cost-effectiveness, it was considered to be an important criterion in priority setting.
"This is what it's all about, how we should use resources in the best way". (Nurse 1, Group 6)
Three different categories that describe three additional dimensions in priority setting were identified: 1) viewpoint (medical or patient's), 2) timeframe (now or later), and 3) evidence level (group or individual).
Viewpoint - medical or patient's
Throughout the focus group discussions two aspects facing the GPs and nurses were apparent: 1) the need to treat the illness and 2) the need to understand the individual patient. These two aspects were often described as the medical viewpoint and the patient's viewpoint.
"I've thought about this, and there are two ways of looking at it. On one hand, there is the medical severity, the seriousness of the disease. But then, there is also the severity of the trouble the disease causes the patient. Although I know that it's harmless, it may be very troublesome to the patient just now. So I have to try to consider both aspects." (GP 3, Group 4)
The GPs referred to these two viewpoints with regard to both severity of the condition and benefit to the patient. The medical viewpoint was based on the use of medical knowledge to estimate the seriousness of the condition and the benefits and risks of different interventions.
"I tried to think of the disease itself, as a disease, and not so much really about how the patient experienced it." (GP 2, Group 3)
(See also Table , Nos. 1-3)
Table 2 Statements from Swedish focus groups with general practitioners (GP) and nurses (N) concerning key priority-setting criteria (severity of the health condition, patient benefit, and cost-effectiveness) that exemplify the category of viewpoint (medical (more ...)
The patients' viewpoint was based on the GPs' or nurses' estimation of how patients experienced their symptoms, how worried the patients felt, and how satisfied the patients would be with the interventions.
"You may be convinced that it's a very mild condition ... but it may still reduce the patient's functional ability due to anxiety. "(GP 1, Group 3)
(See also Table , Nos. 5-7)
Some GPs considered the medical viewpoint more important, or even the only viewpoint that should be considered, especially when estimating patient benefit. However, most of the GPs found it important to take the patient's viewpoint into account and balance the two viewpoints in estimating the severity of the condition and expected patient benefit. Most nurses considered patient satisfaction to be an important aspect of patient benefit, but many GPs said that patient satisfaction is not directly related to the actual benefit of the treatment given.
"The fact that a patient is satisfied only means that you have met his/her demands, but that does not necessarily mean that they have received any special benefit from the treatment." (GP 1, Group 2)
(See also Table , No. 7)
General practitioners and nurses also used the two viewpoints when estimating cost-effectiveness, albeit more indirectly (Table , Nos. 4, 8).
Timeframe - now or later
In most cases the GPs and nurses estimated the severity of the patient's condition from the patient's well-being at the time of the consultation and not by considering future risks:
"I would consider the case of a diabetic under strict surveillance to be of only moderate severity. Perhaps I would not need to perform any intervention during the check-ups since it was already under control. But in the case of a patient who is going downhill, if I could intervene to stop that process in any way it would, of course, be a condition of high severity." (GP 3, Group 1)
General practitioners and nurses found it relatively easy to estimate the severity of a condition in patients with obvious symptoms of a well-defined, usually acute, disease. These types of conditions were often considered more severe than asymptomatic chronic conditions. At times, the severity of a condition was equated with how soon the patient needed an appointment, i.e. acute diseases were considered more severe than chronic diseases that needed check-ups but could wait another day.
"A patient that comes in with severe sepsis is in a critical state and will die if he or she does not receive treatment within a matter of hours. Of course this patient must be given highest priority." (GP 3, Group 4)
(See also Table , Nos. 1, 6).
Statements from Swedish focus groups with general practitioners (GP) and nurses (N) concerning the key priority-setting criteria (severity of health condition, patient benefit, and cost-effectiveness) that exemplify the category of timeframe.
Likewise, estimating patient benefit and cost-effectiveness of an intervention was found to be easier when the intervention was uncomplicated and yielded a quick result that could be easily perceived or measured:
"If someone comes in with a sort of asthma characterised by severe rhonchi and needs inhalation treatment, which will clear it up straight away." (GP 1, Group 3)
(See also Table , Nos. 2-5).
It was more difficult to evaluate patient benefit in asymptomatic patients with chronic conditions and who are at risk for future complications, e.g. diabetes or hypertension. General practitioners expressed difficulties in knowing what benefit a patient would realise in the future from a particular intervention given today.
Moreover, some GPs questioned the value of treating certain chronic conditions, e.g. hypertension. They considered treatment to be overrated, which made the estimation of patient benefit even more difficult.
"A urinary tract infection, and so on, these patients were easier for me to assess. But, for example, a yearly check-up for hypertension where blood pressure was a little too high is difficult for me because there is a greater risk of heart attack and so on, but of course not very high..." (GP 4, Group 1)
(See also Table , Nos. 7-9).
Evidence level - individual or group
In patients presenting with common symptoms, the staff found it easy to estimate severity without questioning the resulting patient benefit and cost-effectiveness.
"Of course, if there is a diabetic with an infection I assess it a little differently than if it is a healthy person with the infection." (GP3, Group 4)
"I had a COPD patient who did not want to quit smoking, who I prescribed medicine to, but I wrote that it would offer a low degree of patient benefit." (GP 3, Group 3)
(See also Table , Nos. 1-4).
Statements from Swedish focus groups with general practitioners (GP) and nurses (N) concerning the key priority-setting criteria (severity of health condition, patient benefit, and cost-effectiveness) that exemplify the category of evidence level.
However, to estimate severity, patient benefit, and cost-effectiveness for a non-symptomatic patient with a chronic disease, the GPs had to base their estimation of risk for complications and the likely benefit of interventions on documented, population-based studies.
"Some patients benefit from it. But you can never know whether a particular patient will benefit." (GP 5, Group 4)
(See also Table , Nos. 5-7)
Applying evidence-based knowledge about study populations to individual patients took place later in the timeframe category, i.e. difficulties associated with estimating how an intervention will affect future risks and benefits.
Moreover, the GPs considered that an individual patient's compliance with lifestyle recommendations would also affect the health outcome. Hence, benefit and cost-effectiveness were dependent not only on the evidence-based intervention, but also on the behaviour of the individual patient.
"I argued that in the case of chronic patients with diabetes and such, if you can manage to convince them when they come to the surgery that there are things they should do to have a good life, then it is cost-effective time. To get them to change their behaviour patterns, getting overweight patients to understand that they must lose weight and such. Then I think that you are highly cost-effective." (GP 1, Group 2)
(See also Table , Nos. 3, 6).