Björn Ekman

Participation in exercise-based cardiac rehabilitation (EBCR) improves long-term prognosis for patients following myocardial infarction (MI). Evaluating the effects of EBCR is challenging due to the voluntary nature of participation in the program. Using register data on 18,978 patients hospitalized for MI in 2011 to 2013 in Sweden, a non-experimental study design is employed to evaluate the effects of EBCR on the health-related quality of life (HRQoL). Conditional independence from non-random treatment assignment is considered through set of potential-outcome (PO) models to estimate the average treatment effect (ATE) and the ATE on the treated (ATET) of EBCR on HRQoL using the EQ-5D-3L instrument. Changes in the EuroQoL Visual Analogue Scale (EQ-VAS; range 0 to 100) and the EQ5D-Index (range -0.594 to 1) between 6-10 weeks and one-year post-MI are compared between two groups of participants in EBCR (complete participants [≥3 months] and non-complete participants [<3 months]) and non-participants (control group). In total, 43% of patients participated in EBCR to some extent (12% complete, 31% non-complete). Participants showed greater improvement on the EQ-VAS scale compared with non-participants. Patients who completed an EBCR program had a larger improvement (ATE of between 1.851-1.917 points; p < 0.001) compared with participants who did not complete the full program (0.974-1.017 points; p < 0.01). Full participation in the program increased the EQ5D-Index of between 0.014 and 0.017 points (p < 0.05), while no statistically significant effect was observed among non-completers. The effect of EBCR on HRQoL was more pronounced among younger patients and those reporting dyspnea and angina than older and non-symptomatic patients. Participating in EBCR may improve the health-related quality of life of patients post-MI. The clinical relevance of the observed impact of EBCR on HRQoL warrants further investigation. The effects of EBCR participation can be readily estimated using broadly applicable non-experimental approaches and commonly available register data.

Background: Primary health care clinics use several different types of consultations, including on-site visits and remote contacts to see patients. However, it is not clear what factors determine the choice of consultation type taking into consideration the full spectrum of options. Objectives: This study uses national register data from Sweden on all primary care consultations in the years 2019 to 2022 (N = 15,3 – 19,5 million) to model four types of consultations: office visits, digital contacts (text messages or video), home visits, and telephone/letter contacts. Methods: The modelling of consultation type takes the cross-sectional, panel, and multilevel structure of the data into consideration fitting multinomial logistic models while controlling for patient, clinic, and context factors. Results: In the current context, the choice of consultation type is determined by both patient (age, socioeconomic status, diagnosis) and clinic (public or private) factors, as well as context factors (reimbursement mechanism). From a policy perspective, only weak evidence is found to suggest that paying clinics for digital contacts increases those types of consultations. Conclusions: The findings may inform the development and implementation of policies and regulations to improve the delivery of primary health care in similar contexts.

Background: The objective of this paper was to estimate the impact of country-wide hospital pay-for-performance on readmissions for a set of common conditions in Lebanon. Methods: This retrospective cohort study included all hospitalizations under the coverage of the Ministry of Public Health in Lebanon between 2011 and 2019. We calculated 30-day all-cause readmissions following general, pneumonia, cholecystectomy and stroke cases. We used an interrupted time series design, including the use of AutoRegressive Integrated Moving Average models. This nationwide study including 1,333,691 hospitalizations was undertaken in Lebanon, using hospitalizations at about 140 private and public hospitals contracted by the Ministry. The participants included citizens across all ages under the Ministry’s coverage (52% of citizens). The intervention was the engagement of hospital leaders by the Ministry, informing them of the addition of a readmissions component to the ongoing pay-for-performance initiative. Engagement participants included hospital directors and managers, and the leadership of the Syndicate of Private Hospitals. The main outcome measure was age-adjusted monthly all-cause readmission rates for each of general, pneumonia, cholecystectomy and stroke cases. We also assessed for change in readmissions for three conditions not included in the intervention (myocardial infarction, cataract surgery and appendectomy). Results: Across 2011–2019, the overall readmission rates were 6.00% (SD 0.24%) for general readmissions, 5.06% (SD 0.22%) for pneumonia, 2.54% (SD 0.16%) for cholecystectomy, and 6.55% (SD 0.25%) for stroke. Using ARIMA models we found a relative percentage decrease in mean monthly readmissions in the post-intervention period for cholecystectomy (5.9%; CI 0.1%-11.8%) and stroke (13.6%; CI 3.1%-24.2%). There was no evidence of intervention impact on pneumonia and general readmissions, both overall and among small, medium and large hospitals. There was also no evidence of change in non-P4P readmissions of myocardial infarction, cataract surgery and appendectomy. Conclusions: Including readmissions within pay-for-performance has the potential to improve hospital performance and patient outcomes, even in countries with more limited resources. Effects may vary across conditions, indicating the need for careful design and understanding of the particular context, both with respect to implementation and to evaluation of impact.

ObjectivesTo describe changes in Swedish primary care physicians' use of, attitudes and intentions toward digital tools in patient care between 2019 and 2022.DesignA survey using a validated questionnaire measuring physician's intentions to use digital tools based on the theory of planned behavior.SettingSample of primary health care centers in southern Sweden.SubjectsPrimary care physicians.Main outcome measuresSelf-reported use and intentions to use, digital tools including digital consultations by text or video, chronic disease monitoring and artificial intelligence (AI) and the associations between attitudes, subjective norms, perceived behavioral control and behavioral intentions to use digital tools, in 2019 compared to 2022.ResultsIn both 2019 (n = 198) and 2022 (n = 93), physicians reported high intentions to use digital tools. Self-reported use of video was slightly higher in 2022 (p = .03). No other changes were seen in the self-reported use or behavioral intentions to use digital tools.ConclusionThe slow adoption of patient-related digital tools in Swedish primary health care does not seem to be explained by a low intention to use them among physicians. Future research on implementation of digital tools should include a focus on contextual factors such as organizational, technical and cultural barriers. Based on the theory of planned behavior a survey was designed and applied in 2019 to measure physicians' use of, attitudes and intentions toward telemedicine (PAIT) and digital tools.A follow up study using PAIT was conducted in 2022.Physicians reported high intentions to use digital tools in both 2019 and 2022.Self-reported use of digital tools was low in both 2019 and 2022.

Using data on 119 low- and lower-middle income countries from 2002 to 2020, we apply fixed-effects (FE) methods to evaluate the impacts of three different classifications of development assistance on access to three types of sexual and reproductive health (SRH) services: access to skilled birth attendance, prevalence of modern contraceptives, and coverage of antiretroviral therapies against HIV/AIDS. The results suggest that aid has had a small, but positive effect on these outcomes over this period. For example, SRH aid has increased service coverage rates by between 0.190 and 0.628 percentage points. The results also indicate that the effect of aid has improved across the period and is larger in low-income countries compared with lower-middle income countries. The findings also indicate that bilateral aid may be somewhat more effective than other types of aid. Importantly, the results suggest that development assistance is more effective if it reaches a certain share of overall health spending. The findings are robust to a series of sensitivity checks. The results of the study lend support to the continued allocation of aid to low-income countries to support the provision of sexual and reproductive health services. Both providers and recipients of SRH aid would be advised to identify ways to improve the effectiveness of development assistance in this area.

Information on standards including structure- and process-based metrics and how exercise-based cardiac rehabilitation (EBCR) is delivered in relation to guidelines is lacking. The aims of the study...