Papers by Ulf-Göran Gerdtham
Factors affecting chronic obstructive pulmonary disease (COPD)-related costs: a multivariate anal... more Factors affecting chronic obstructive pulmonary disease (COPD)-related costs: a multivariate analysis of a Swedish COPD cohort.
International Journal of Environmental Research and Public Health, 2020
Using observational data to assess the treatment effects on outcomes of kidney transplantation re... more Using observational data to assess the treatment effects on outcomes of kidney transplantation relative to dialysis for patients on renal replacement therapy is challenging due to the non-random selection into treatment. This study applied the propensity score weighting approach in order to address the treatment selection bias of kidney transplantation on survival time compared with dialysis for patients on the waitlist. We included 2676 adult waitlisted patients who started renal replacement therapy in Sweden between 1 January 1995, and 31 December 2012. Weibull and logistic regression models were used for the outcome and treatment models, respectively. The potential outcome mean and the average treatment effect were estimated using an inverse-probability-weighted regression adjustment approach. The estimated survival times from start of renal replacement therapy were 23.1 years (95% confidence interval (CI): 21.2−25.0) and 9.3 years (95% CI: 7.8−10.8) for kidney transplantation an...
International journal of environmental research and public health, Feb 27, 2018
Willingness-to-pay (WTP) techniques are increasingly being used in the healthcare sector for asse... more Willingness-to-pay (WTP) techniques are increasingly being used in the healthcare sector for assessing the value of interventions. The objective of this study was to estimate WTP and its predictors in a randomized controlled trial of a lifestyle intervention exclusively targeting Middle Eastern immigrants living in Malmö, Sweden, who are at high risk of type 2 diabetes. We used the contingent valuation method to evaluate WTP. The questionnaire was designed following the payment-scale approach, and administered at the end of the trial, giving an ex-post perspective. We performed logistic regression and linear regression techniques to identify the factors associated with zero WTP value and positive WTP values. The intervention group had significantly higher average WTP than the control group (216 SEK vs. 127 SEK; = 0.035; 1 U.S.$ = 8.52 SEK, 2015 price year) per month. The regression models demonstrated that being in the intervention group, acculturation, and self-employment were sign...
Social Science & Medicine, 2005
We assess the relationship between business cycles and mortality risk using a large individual le... more We assess the relationship between business cycles and mortality risk using a large individual level data set on over 40,000 individuals in Sweden who were followed for 10-16 years (leading to over 500,000 person-year observations). We test the effect of six alternative business cycle indicators on the mortality risk: the unemployment rate, the notification rate, the deviation from the GDP trend, the GDP change, the industry capacity utilization, and the industry confidence indicator. For men we find a significant countercyclical relationship between the business cycle and the mortality risk for four of the indicators and a non-significant effect for the other two indicators. For women we cannot reject the null hypothesis of no effect for any of the business cycle indicators.
PharmacoEconomics, 2004
2000. This paper updates a previous study, which looked at the period 1990-1995, by providing an ... more 2000. This paper updates a previous study, which looked at the period 1990-1995, by providing an additional 5 years of data (1995-2000) and extending the previous analysis in a number of ways. Methods: The paper builds on the earlier work that showed that changes in drug spending could be decomposed into three components: price, quantity and a residual. The size of the residual is a measure of the impact of changes in drug treatment patterns on drug spending. The data set used in this paper was collected from Apoteket AB (The National Corporation of Swedish Pharmacies) and was based on comprehensive information (inpatients as well as outpatients) on drug deliveries from wholesalers to pharmacies. Data were obtained for aggregate drug spending (from 1990-2000) and for spending according to anatomical therapeutic chemical (ATC) classification system group. Results: Real drug spending increased by 119% during the study period. The residual rose by 67% indicating the switch from cheaper to more innovative and expensive drug therapies was a major cost driver. Real drug spending would have increased by about 31% if there had been no changes in treatment patterns. The second driver of drug spending was the quantity of drugs consumed, which increased by 41%. The main reason for the larger quantity sold appears to be increases in the intensity of medication in terms of defined daily doses per patient, rather than a larger number of patients starting drug treatment. Real prices decreased during the 10-year study period. We found large differences between ATC groups in terms of spending growth. The ATC groups that have contributed the most to the increase in spending are: drugs that affect the CNS (N), the alimentary tract and metabolism (A) and the cardiovascular system (C), which are also the three largest groups in terms of sales. For all three groups, it was the residual that mainly drove costs. This study indicates very clearly that the main driving force behind the increase in drug costs in Sweden between 1990 and 2000 was the change in drug therapy from old to new and more innovative and expensive drug therapies. This shows the importance of carrying out economic evaluations of new more 1 See Dubois et al. for a similar decomposition and also Crown et al. for an examination of methodological approaches that have been used to analyse trends in medical and pharmaceutical expenditures.
Medical Care, 2005
In high-risk births, the availability and concentration of neonatal resources in larger regional ... more In high-risk births, the availability and concentration of neonatal resources in larger regional hospitals increases the chance of survival. The advantages of regionalization for low-risk deliveries are still unclear, but some studies have suggested that regionalization also is beneficial for low risk deliveries. The aim of the present study was to investigate both the relevance of regionalization and the concentration of neonatal resources as determinants of mortality in low-and high-risk deliveries in Sweden. Methods: Interhospital differences in 28-day neonatal mortality were analyzed distinguishing maternal and delivery factors from institutional ones. Using information from the Swedish Birth Register (1990 -1995), we performed risk-stratified multilevel logistic regression analysis to study 691,742 births (first level) nested within the 66 Swedish hospitals with maternity wards (second level). Results: In low-risk deliveries, mortality decreased with improved access to neonatal resources. Mortality was lowest in larger regional hospitals with full access to neonatal care. This association remained unchanged after adjusting for patient mix. With regard to high-risk deliveries, mortality was higher in large county and regional hospitals than in small hospitals without access to neonatal care but, as expected, this increased risk disappeared after adjustment for patient mix. Conclusions: Increased regionalization and concentration of neonatal resources for low-risk births is justified from a strictly medical point of view. From a public health perspective, closing small obstetrics units may prevent an appreciable number of deaths, but it would have only a very small impact on the risk of mortality from the individual's point of view. The cost-effectiveness of such a step remains to be analyzed from a health economics perspective.
Health Economics, Policy and Law, 2006
We test whether individual health status is related to area-level social capital measured by rate... more We test whether individual health status is related to area-level social capital measured by rates of voting participation in municipal political elections, controlling for personal characteristics, where health status is measured by mapping responses to interview survey questions into the generic health-related quality of life measure (HRQoL) the EQ-5D in order to derive the health state scores. The analysis is based on unbalanced panel data from Statistic Sweden's Survey of Living Conditions (the ULF survey) and a 3-level multilevel regression analysis, where level 1 consists of a total of 31,585 observations for 24,419 individuals at level 2 nested within 275 Swedish municipalities at level 3. We find that the health state scores increase significantly with municipality election rates. This result is robust to a number of measurement and specification issues explored in a sensitivity analysis. However, almost all variation in health status exists across individuals (more than...
Health Economics, 2003
In recent work, the concentration index has been widely used as a measure of income‐related healt... more In recent work, the concentration index has been widely used as a measure of income‐related health inequality. The purpose of this note is to illustrate two different methods for decomposing the overall health concentration index using data collected from a Short Form (SF‐36) survey of the general Australian population conducted in 1995. For simplicity, we focus on the physical functioning scale of the SF‐36. Firstly we examine decomposition ‘by component’ by separating the concentration index for the physical functioning scale into the ten items on which it is based. The results show that the items contribute differently to the overall inequality measure, i.e. two of the items contributed 13% and 5%, respectively, to the overall measure. Second, to illustrate the ‘by subgroup’ method we decompose the concentration index by employment status. This involves separating the population into two groups: individuals currently in employment; and individuals not currently employed. We find ...
Expert Review of Pharmacoeconomics & Outcomes Research, 2004
The objective of this review is to examine how drug spending in different age groups changed duri... more The objective of this review is to examine how drug spending in different age groups changed during the 1990s. Time series analysis of registered data on prescription drug spending were performed, along with two decompositions, one of which was spending in three components: price, quantity (defined daily dose) and residual. The size of the residual is a measure of the impact of changes in drug treatment patterns on drug spending. The other decomposition was of the quantity component in three subcomponents: defined daily doses per person on medication, population share on medication and population size. Both decompositions are made separately for different age groups. How spending for different age groups has developed in different therapeutic areas was also studied. The main outcome measures were prescription drug spending over time within different anatomical therapeutic chemical groups and across different age groups of the population. It was found that the older the age group, the more drug spending had increased, both in absolute and in relative terms, during the 1990s. However, for some anatomical therapeutic chemical groups, younger age groups have experienced faster spending growth. The most notable example being anatomical therapeutic chemical group N CNS, where spending grew fastest by 350%, for those aged between 20 and 39 years. Furthermore, changed treatment patterns, such as a switch to more expensive drugs, is the main explanation for higher spending in all age groups. Higher spending is also due to a larger number of defined daily doses sold, which is almost totally due to the fact that each person on medication in the year 2000 utilized more defined daily doses than in 1990. Changing age structure explains a negligible share of the increase in drug spending, but elderly patients did have a key role in the spending surge since they increased their per capita spending the most.
Health Economics, 2009
This paper explains and empirically assesses the channels through which population aging may impa... more This paper explains and empirically assesses the channels through which population aging may impact on income‐related health inequality. Long panel data of Swedish individuals is used to estimate the observed trend in income‐related health inequality, measured by the concentration index (CI). A decomposition procedure based on a fixed effects model is used to clarify the channels by which population aging affects health inequality. Based on current income rankings, we find that conventional unstandardized and age–gender‐standardized CIs increase over time. This trend in CIs is, however, found to remain stable when people are instead ranked according to lifetime (mean) income. Decomposition analyses show that two channels are responsible for the upward trend in unstandardized CIs – retired people dropped in relative income ranking and the coefficient of variation of health increases as the population ages. Copyright © 2009 John Wiley & Sons, Ltd.
The European Journal of Health Economics, 2007
Addiction, 2012
ABSTRACTAim To establish the current level of knowledge of the effect of drinking cessation on t... more ABSTRACTAim To establish the current level of knowledge of the effect of drinking cessation on the risk of developing oesophageal cancer.Method A meta‐analysis was conducted based on relevant studies identified through a systematic literature review. A generalized least squares model for trend estimation of summarized dose–response data were utilized in order to estimate the effect of years since drinking cessation on risk of oesophageal cancer.Result Seventeen studies that estimate the risk reduction after quantified drinking cessation were identified in the systematic literature review. Nine of these were appropriate for inclusion in the meta‐analysis. A large degree of heterogeneity existed between the studies, but this was explainable and the increased risk of oesophageal cancer caused by alcohol consumption was found to be reversible, with a common trend between studies. A required time‐period of 16.5 years (95% confidence interval 12.7–23.7) was estimated until no risk from...
Social Science & Medicine, 2010
Using longitudinal data over a 17-year period for a Swedish cohort aged 20-68 in 1980/1981, this ... more Using longitudinal data over a 17-year period for a Swedish cohort aged 20-68 in 1980/1981, this study analyses income-related inequalities in obesity. By using the concentration index and decomposition techniques we answer the following questions: 1) Does obesity inequality disfavour the poor? 2) What factors explain the inequality at different points in time? 3) What explains the change in inequality between years? We find that among females, inequalities in obesity favour the rich, but the inequality declines over time. Income itself is the main driving force behind obesity inequality, whereas being single (as opposed to being married or cohabiting) is an important counteracting factor. The main reason for the reduced obesity inequality over time is increased obesity prevalence, because in absolute terms obesity has increased uniformly across income groups. Because the income elasticity of obesity is the single most important contributor to the inequality, policies directed towards this factor might be the most effective for reducing obesity inequality. Our main income variable is within-individual mean of income, and we thereby focus on long-run inequality and are able to standardize for income mobility. The results show that inequality based on short-run income differs substantially from inequality based on long-run income. For males we find similar inequality trends as for women, although less pronounced. This difference between men and women should be taken into account when evaluating obesity reducing policies.
BMJ Global Health
Introduction Universal Health Coverage is not only about access to health services but also about... more Introduction Universal Health Coverage is not only about access to health services but also about access to high-quality care, since poor experiences may deter patients from accessing care. Evidence shows that quality of care drives health outcomes, yet little is known about non-clinical dimensions of care, and patients’ experience thereof relative to satisfaction with visits. This paper investigates the role of non-clinical dimensions of care in patient satisfaction. Methods Our study describes the interactions of informed and non-informed patients with primary healthcare workers at 39 public healthcare facilities in two metropolitan centres in two South African provinces. Our analysis included 1357 interactions using standardised patients (for informed patients) and patients’ exit interviews (for non-informed patients). The data were combined for three types of visits: contraception, hypertension and tuberculosis. We describe how satisfaction with care was related to patients’ exp...
Value in Health, 2012
several sources of real world data available to researchers. METHODS: We compare and contrast the... more several sources of real world data available to researchers. METHODS: We compare and contrast the pros and cons of data available from administrative (payment) databases, electronic medical record (EMR) databases, and surveys. RESULTS: Administrative claims databases provide fully-integrated, all-encounter patient data on diagnoses, procedures, and payments. However, data quality varies depending upon whether particular fields are required for provider payment. Data on lab and test values are typically lacking. Prescriptions that are written, but not filled by the patient, are usually not captured. Medical record data overlap, to a certain extent, with administrative data. While information on payments for services may not be included, detailed information on test results and lab values are usually captured in the EMR. Data are included on written prescriptions, but the researcher will not know whether the prescription was filled by the patient. Depending upon the clinical system covered, only some encounters (e.g., ambulatory care in the outpatient setting) may be available. Both administrative and EMR data hold the potential to provide longitudinal patient information that is not subject to recall or social desirability biases that often affect survey data. However, information on satisfaction with care, quality of life, activities of daily living, and many other metrics, may only be captured with survey data. CONCLUSIONS: Several sources of rich, longitudinal patient data are available to provide real world evidence on drug effectiveness and cost. In some cases, data may be combined to overcome limitations of a single source. With care, data may be found that will produce generalizable findings for the population of interest.
Nordic Journal of Health Economics, 2011
The purpose of this study is threefold; 1) to establish the current level of knowledge regarding ... more The purpose of this study is threefold; 1) to establish the current level of knowledge regarding cost-effectiveness of organ transplantation, 2) to identify knowledge gaps, and 3) to suggest a framework for future studies. A systematic literature review of economic evaluations of transplantations of solid organs was conducted in October 2010. Economic evaluations published since 2000 and reviews published since 1987 for kidney, liver, lung, heart, pancreas, and small bowel transplantations were collected. The studies were analysed regarding results and study characteristics. The review demonstrates a lack of economic evaluations for all included organ transplantations. The cost-effectiveness of kidney transplantation, and to some extent liver transplantation, compared to a non-transplant alternative appears to be established. However, cost-effectiveness for transplantation of lung, heart, pancreas, and small bowel can neither be established nor rejected based on earlier studies. Man...
Value in Health, 2013
A633 and ER tolterodine patients remained on treatment until week 52, respectively. QALYs were hi... more A633 and ER tolterodine patients remained on treatment until week 52, respectively. QALYs were higher with fesoterodine than tolterodine (0.762 vs. 0.760). In Spain, fesoterodine treatment had higher costs than (generic) ER tolterodine (€ 6 697 vs. € 6 597), resulting in a cost of € 15 600/QALY gained. In Finland, fesoterodine was cost-saving relative to (non-generic) ER tolterodine (€ 7 885 vs. € 8 024). Sensitivity analysis confirmed these findings were robust to the expected price decrease for generic ER tolterodine in Finland. In the PSA, fesoterodine was consistently the preferred therapy in Finland regardless of the value of a QALY and in Spain for QALY valuations greater than € 15 000. ConClusions: Fesoterodine is cost-effective or cost-saving relative to ER tolterodine for the treatment of OAB with UUI in two European countries. Payers and prescribers should consider a broad scope of costs in order to make informed costconscious choices of antimuscarinic treatment.
The aim of the paper is to critically review the notion of social capital and review empirical li... more The aim of the paper is to critically review the notion of social capital and review empirical literature on the association between social capital and health across countries. The methodology used for the review includes a systematic search on electronic databases for peer-reviewed published literature. We categorize studies according to level of analysis (single and multilevel) and examine whether studies reveal a significant health impact of individual and area level social capital. We compare the study conclusions according to the country's degrees of economic egalitarianism. Regardless of study design, our findings indicate that a positive association (fixed effect) exists between social capital and better health irrespective of countries degree of egalitarianism. However, we find that the between-area variance (random effect) in health tends to be lower in more egalitarian countries than in less egalitarian countries. Our tentative conclusion is that an association between social capital and health at the individual level is robust with respect to the degree of egalitarianism within a country. Area level or contextual social capital may be less salient in egalitarian countries in explaining health differences across places.
Background: The term "reproductive, maternal, newborn, and child health (RMNCH)" describes an int... more Background: The term "reproductive, maternal, newborn, and child health (RMNCH)" describes an integrated continuum of health states which is central to Millennium Development Goals 4 and 5. While the burden of mortality and morbidity associated with RMNCH is well known, knowledge is still limited about the economic burden of RMNCH. Concrete evidence of cost of illness (COI) of RMNCH may help policy makers in supporting investment in RMNCH. Methods: A systematic literature search of COI studies was performed in electronic databases. The time frame for the analysis was January 1990-April 2011. The databases checked were Medline (Pubmed), Embase and ECONbase, EconLit, the Cumulative Index to Nursing and Allied Health (CINAHL), the National Bureau of Economic Research, the Latin American and Caribbean Literature on Health Sciences Database (LILACS), and Popline. Furthermore, we searched working papers and reference lists of selected articles. Results: All the studies investigated address particular complications and issues of RMNCH, e.g., preterm birth, non-exclusive breastfeeding, and sexually transmitted diseases (STDs), but not RMNCH as an entire continuum. Most of the studies were conducted in high income countries, with limited data on low and middle income countries. The burden of disease is very high even for single complications. For example, the disease burden related to non-exclusive breastfeeding was given as 14.39 billion international dollars (ID) (2012, purchasing power parity) per year in the USA. Methodological differences in study design, costing approach, perspective of analysis, and time frame make it difficult to compare different studies. Conclusion: The continuum of RMNCH covers a large portion of the lifespan from birth through the reproductive age. From a methodological perspective, an ideal COI study would clearly describe the perspective of analysis and, hence, the cost items (direct or indirect), cost collection procedure, discounting, quality of data, time frame of analysis, related comorbidities, and robust sensitivity analysis for all the assumptions. Further research is needed to measure the economic impact of RMNCH, including identification of the most cost-effective policy and interventions for prevention, reduction, and elimination of the complications of RMNCH.
The aim of the current study was to provide updated time-path equations for risk factors of type-... more The aim of the current study was to provide updated time-path equations for risk factors of type-2-diabetes-related cardiovascular complications for application in risk calculators and health economic models. Observational data from the Swedish National Diabetes Register were analysed using Generalized Method of Moments estimation for dynamic panel models (= 5, 043, aged 25-70 years at diagnosis in 2001-2004). Validation was performed using persons diagnosed in 2005 (= 414). Results were compared with the UKPDS outcome model. The value of the risk factor in the previous year was the main predictor of the current value of the risk factor. People with high (low) values of risk factor in the year of diagnosis experienced a decreasing (increasing) trend over time. BMI was associated with elevations in all risk factors, while older age at diagnosis and being female generally corresponded to lower levels of risk factors. Updated time-path equations predicted risk factors more precisely than UKPDS outcome model equations in a Swedish population. Findings indicate new time paths for cardiovascular risk factors in the post-UKPDS era. The validation analysis confirmed the importance of updating the equations as new data become available; otherwise, the results of health economic analyses may be biased.
Uploads
Papers by Ulf-Göran Gerdtham