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1.  Setting priorities in primary health care - on whose conditions? A questionnaire study 
BMC Family Practice  2012;13:114.
Background
In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients.
Methods
Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected.
Results
Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness.
Conclusions
The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.
doi:10.1186/1471-2296-13-114
PMCID: PMC3528614  PMID: 23181453
2.  GPs´ decision-making - perceiving the patient as a person or a disease 
BMC Family Practice  2012;13:38.
Background
The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work.
Methods
A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients.
Results
68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person.
Conclusions
The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.
doi:10.1186/1471-2296-13-38
PMCID: PMC3464802  PMID: 22591163
3.  How does comorbidity influence healthcare costs? A population-based cross-sectional study of depression, back pain and osteoarthritis 
BMJ Open  2012;2(2):e000809.
Objectives
To analyse how comorbidity among patients with back pain, depression and osteoarthritis influences healthcare costs per patient. A special focus was made on the distribution of costs for primary healthcare compared with specialist care, hospital care and drugs.
Design
Population-based cross-sectional study.
Setting
The County of Östergötland, Sweden.
Patients
Data on diagnoses and healthcare costs for all 266 354 individuals between 20 and 75 years of age, who were residents of the County of Östergötland, Sweden, in the year 2006, were extracted from the local healthcare register and the national register of drug prescriptions.
Main outcome measures
The effects of comorbidity on healthcare costs were estimated as interactions in regression models that also included age, sex, number of other health conditions and education.
Results
The largest diagnosed group was back pain (11 178 patients) followed by depression (7412 patients) and osteoarthritis (5174 patients). The largest comorbidity subgroup was the combination of back pain and depression (772 patients), followed by the combination of back pain and osteoarthritis (527 patients) and the combination of depression and osteoarthritis (206 patients). For patients having both a depression diagnosis and a back pain diagnosis, there was a significant negative interaction effect on total healthcare costs. The average healthcare costs among patients with depression and back pain was SEK 11 806 lower for a patient with both diagnoses. In this comorbidity group, there were tendencies of a positive interaction for general practitioner visits and negative interactions for all other visits and hospital days. Small or no interactions at all were seen between depression diagnoses and osteoarthritis diagnoses.
Conclusions
A small increase in primary healthcare visits in comorbid back pain and depression patients was accompanied with a substantial reduction in total healthcare costs and in hospital costs. Our results can be of value in analysing the cost effects of comorbidity and how the coordination of primary and secondary care may have an impact on healthcare costs.
Article summary
Article focus
Comorbidity is often associated with high healthcare costs and raises questions that are of interest for the organisation of primary and secondary healthcare, for example, what is the impact on healthcare costs?
Is there an increase in costs because the complexity is high in the management of the different diseases? Or maybe there is a decline in costs due to an efficient handling and therefore a lower numbers of healthcare contacts for single persons with many diseases?
Key messages
The comorbidity influence on healthcare costs tended to be less—not more—than additive and among patients with back pain and depression, significantly less than additive.
Strengths and limitations of this study
The possibility to measure total healthcare utilisation on an individual level both in primary care and hospital care was an advantage in this study.
There are broad clinical variations in register data, for instance variations in the definition of diagnoses. An under-reporting of diagnoses in the medical records is common, especially in primary care.
doi:10.1136/bmjopen-2011-000809
PMCID: PMC3341593  PMID: 22535792
4.  Priority setting in primary health care - dilemmas and opportunities: a focus group study 
BMC Family Practice  2010;11:71.
Background
Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria.
Methods
Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work.
Results
The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patient's), 2) timeframe (now or later), and 3) evidence level (group or individual).
Conclusions
The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.
doi:10.1186/1471-2296-11-71
PMCID: PMC2955602  PMID: 20863364
5.  Primary care patients’ attitudes to priority setting in Sweden 
Objective
To analyse attitudes to priority setting among patients in Swedish primary healthcare.
Design
A questionnaire was given to patients comprising statements on attitudes towards prioritizing, on the role of politicians and healthcare staff in prioritizing, and on patient satisfaction with the outcome of their contact with primary healthcare (PHC).
Settings
Four healthcare centres in Sweden, chosen through purposive sampling.
Participants
All the patients in contact with the health centres during a two-week period in 2004 (2517 questionnaires, 72% returned).
Main outcomes
Patient attitudes to priority setting and satisfaction with the outcome of their contact.
Results
More than 75% of the patients agreed with statements like “Public health services should always provide the best possible care, irrespective of cost”. Almost three-quarters of the patients wanted healthcare staff rather than politicians to make decisions on priority setting. Younger patients and males were more positive towards priority setting and they also had a more positive view of the role of politicians. Less than 10% of the patients experienced some kind of economic rationing but the majority of these patients were satisfied with their contact with primary care.
Conclusions
Primary care patient opinions concerning priority setting are a challenge for both politicians and GPs. The fact that males and younger patients are less negative to prioritizing may pave the way for a future dialogue between politicians and the general public.
doi:10.1080/02813430902883901
PMCID: PMC3410460  PMID: 19466679
Health priorities; family practice; patient participation; patient satisfaction; primary healthcare; rationing

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