From office to digital primary care services: analysing income-related inequalities in utilization.

The use of digital technologies to deliver primary health care has increased over the past decade. While some technologies have been shown to be medically effective and efficient, the effects of digital primary care on the policy goal of equality in the use of such types of care have not been studied using large register data. The aim of this study was to analyse how digital contacts differ from officebased visits by income as an indicator of socioeconomic status. Specifically, we estimated differences in primary care utilization across income, factors of contribution to these inequalities, and applied a needs-based standardisation of utilization to estimate differences in equity.We used a purposively built consultation level dataset with 726 000 Swedish adult patients diagnosed with an infection, including clinical and sociodemographic variables. Applying concentration indexes (CI) and graphical illustrations we measured how the two types of services are distributed relative to income. We estimated how much of the inequalities were attributed to different sociodemographic factors by decomposing the concentration indexes. Standardised utilization for sex, age and comorbidity allowed for the estimation of horizontal inequity indexes for both types of services.Utilization by the two types of care showed large income inequalities. Office-based visits were propoor (CI -0.116), meaning lowincome patients utilized relatively more of these services, while digital contacts were prorich (CI 0.205). However, within the patient group who had at least one digital contact, the utilization was also propoor (CI -0,101), although these patients had higher incomes on average. The standardised utilization showed a smaller prorich digital utilization (CI 0.143), although large differences remained. Decomposing the concentration indexes showed that education level and being born in Sweden were strong attributes of prorich digital service utilization.The prorich utilization effects of digital primary care may risk undermining the policy goals of access and utilization to services regardless of socioeconomic status. As digital health technologies continue to expand, policy makers need to be aware of the risk.

Effect of Individual Rate of Inbreeding, Recent and Ancestral Inbreeding on Wool Quality, Muscling Conformation and Exterior in German Sheep Breeds.

This study provides comprehensive results on the current status of inbreeding depression for traits upon which sheep are selected for the herdbook in Germany. A total of 30 sheep breeds from the OviCap national database met the inclusion criteria for the present analysis regarding the depth and completeness of pedigrees and the number of animals with phenotypic data. We analyzed heritabilities and inbreeding depression for the three breeding objective traits of wool quality, muscling conformation and exterior. Heritabilities were across all breeds of moderate size, with estimates of 0.18 for wool quality and muscling conformation and of 0.14 for exterior. The models employed to estimate linear regression slopes for individual and ancestral inbreeding rates also account for non-genetic effects and the additive genetic effect of the animal. Inbreeding depression was obvious for all three traits when we averaged the estimates across all 30 sheep breeds. Inbreeding depression was significant for wool quality for only a few breeds, whereas for muscling conformation, 14/30 breeds achieved significant estimates. A 1% increase in inbreeding decreased the mean of all three traits across all sheep breeds by 0.33% of their standard deviation. Positive effects due to ancestral inbreeding were only significant in very few breeds in the different traits. Across all 30 sheep breeds, there were indications that purging effects (a reduction in negative effects of inbreeding depression due to selection for heterozygotes) may play a role for the exterior. The results of this study should help for reviewing breeding programs, particularly for sheep breeds with critical effective population sizes and increasing rates of inbreeding, with regard to the selection policy and selection intensity applied.

Inbreeding Depression and Purging for Meat Performance Traits in German Sheep Breeds.

This study provides estimates on genetic parameters, inbreeding depression and purging for meat performance measures from 25 German sheep breeds. All German meat, merino sheep breeds and breeds of other breeding directions with a sufficient number of pedigree and performance data were included in this study. Phenotypic traits retrieved from the national database OviCap were evaluated: daily weight gain, meatiness score and ultrasound measurements for muscle and fat thickness. We employed animal models to estimate heritability, variance and covariance components for these meat performance traits as well as inbreeding depression and purging. The heritabilities, on average, reached estimates of 0.55, 0.34, 0.53 and 0.61 for daily weight gain, meatiness score and ultrasound measurements for muscle and fat thickness, respectively. We estimated the linear regression slopes for the individual rate of inbreeding, new and ancestral inbreeding, as well as the inbreeding coefficient and its interaction with the inbreeding coefficient of Ballou, employing animal models with non-genetic effects and the additive genetic effect of the animal. Across all breeds, inbreeding was only significant for daily weight gain, whereas for all other traits, estimates were not significant. Within sheep breeds, we found significant inbreeding depression for daily weight gain in German Mutton Merino and German Blackheaded Mutton as well as for the meatiness score in German Whiteheaded Mutton. Significant effects for purging, based on ancestral inbreeding and the interaction effect of the classical inbreeding coefficient with the inbreeding coefficient of Ballou, were not obvious either across or within any sheep breed. A 1% increase in inbreeding significantly decreased the phenotypic trait median of daily weight gain across all sheep breeds by 0.50% and 0.70% of phenotypic and genetic standard deviation, respectively. Purging effects due to ancestral inbreeding were not significant in any breed or across breeds. The results of this study may indicate that inbreeding depression may be more harmful in traits under stronger selection than in traits that exert low selection pressure. The results of this study demonstrate the different effects that result in meat performance traits due to inbreeding. With increasing rates of inbreeding and critical effective population sizes, selection intensity for breeding objectives has to be critically reviewed for each sheep breed. Inbreeding depression and purging should be evaluated in order to prevent a decrease in trait means due to inbreeding and to determine whether detrimental alleles are eliminated.

Genetic Diversity and Trends of Ancestral and New Inbreeding in German Sheep Breeds by Pedigree Data.

In Germany, many autochthonous sheep breeds have developed, adapted to mountain, heath, moorland, or other marginal sites, but breeds imported from other countries have also contributed to the domestic breeds, particularly improving wool and meat quality. Selective breeding and the intense use of rams may risk losing genetic diversity and increasing rates of inbreeding. On the other hand, breeds with a low number of founder animals and only regional popularity may not leave their endangered status, as the number of breeders interested in the breed is limited. The objective of the present study was to determine demographic measures of genetic diversity and recent as well as ancestral trends of inbreeding in all autochthonous German sheep breeds and sheep of all breeding directions, including wool, meat, and milk. We used pedigree data from 1,435,562 sheep of 35 different breeds and a reference population of 981,093 sheep, born from 2010 to 2020. The mean number of equivalent generations, founders, effective founders, effective ancestors, and effective founder genomes were 5.77, 1669, 123.2, 63.5, and 33.0, respectively. Genetic drift accounted for 69% of the loss of genetic diversity, while loss due to unequal founder contributions was 31%. The mean inbreeding coefficient, individual rate of inbreeding (∆Fi), and realized effective population size across breeds were 0.031, 0.0074, and 91.4, respectively, with a significantly decreasing trend in ∆Fi in 11/35 breeds. New inbreeding, according to Kalinowski, contributed to 71.8% of individual inbreeding, but ancestral inbreeding coefficients showed an increasing trend in all breeds. In conclusion, in our study, all but one of the mountain-stone sheep breeds and the country sheep breed Wald were the most vulnerable populations, with Ne < 50. The next most endangered breeds are exotic, country, and heath breeds, with average Ne of 66, 83, and 89, respectively. The wool, meat, and milk breeds showed the highest genetic diversity, with average Ne of 158, 120, and 111, respectively. The results of our study should help strengthen conservation program efforts for the most endangered sheep breeds and maintain a high genetic diversity in all sheep breeds.

Фазои буҷетӣ барои тандурустӣ дар Ҷумҳурии Тоҷикистон: имкониятҳои ҷалби захираҳои давлатии иловагӣ

Барномаи ислоҳоти соҳаи тандурустии Ҷумҳурии Тоҷикистон ҷиҳати ноил шудан ба фарогирии умумӣ бо хизматрасониҳои тандурустӣ (ФУХТ) аз беҳтар намудани дастрасии тамоми аҳолӣ ба хизматрасонии тиббии баландсифат ва истифодаи самараноки захираҳои давлатӣ иборат аст. Стратегияи миллии тандурустии ба наздикӣ қабулшуда (Стратегияи ҳифзи солимии аҳолии Ҷумҳурии Тоҷикистон барои давраи то соли 2030) ба далелҳо ва тавсияҳои глобалӣ пайравӣ намуда, ба тавсеаи кумаки аввалияи тиббию санитарӣ такя мекунад. Барои татбиқи стратегия ба Ҷумҳурии Тоҷикистон лозим аст, ки маблағгузории давлатиро ба соҳаи тандурустӣ ба таври қобили мулоҳиза зиёд намояд ва захираҳоро ба он соҳае ҷудо намояд, ки онҳо самараи бештар доранд. Дар айни замон, захираҳои буҷетӣ барои кӯмаки аввалияи тиббию санитарӣ кофӣ нестанд ва дар саросари кишвар нобаробар тақсим карда мешаванд, ки дар натиҷа камбудиҳои ноодилона дар дастрасии хизматрасонии тиббӣ ба вуҷуд меоянд. Аз ин рӯ, дар истифодаи соҳаи тандурустӣ фарқиятҳои беасос вуҷуд доранд. Дар гузориши мазкур имкониятҳои алтернативии зиёд кардани фазои буҷетӣ барои саломатӣ, аз ҷумла захираҳои кӯмаки аввалияи тиббию санитарӣ тавсиф, таҳлил ва муқоиса шудаанд.

Фискальное пространство для сектора здравоохранения в Республике Таджикистан: варианты получения дополнительных финансовых ресурсов

Программа реформы здравоохранения Республики Таджикистан для достижения всеобщего охвата услугами здравоохранения (ВОУЗ) включает в себя улучшение доступа к качественной медицинской помощи для всего населения и более эффективное использование государственных ресурсов. Недавно принятая Национальная стратегия здравоохранения (Стратегия охраны здоровья населения Республики Таджикистан на период до 2030 г.) следует глобальным фактическим данным и рекомендациям и основывается на расширении первичной медико-санитарной помощи. Для реализации стратегии Республике Таджикистан необходимо в значительной степени увеличить государственное финансирование здравоохранения и направить ресурсы туда, где они дадут наибольший эффект. В настоящее время бюджетные ресурсы на первичную медико-санитарную помощь отстают и неравномерно распределяются по стране, что приводит к несправедливым пробелам в доступе к медицинской помощи. Следовательно, существуют необоснованные различия в использовании медицинских услуг. В этом отчете описываются, анализируются и сравниваются альтернативные возможности увеличения фискального пространства для здравоохранения, в частности ресурсов для первичной медико-санитарной помощи.

Budgetary space for health in the Republic of Tajikistan: options for more public resources

The Republic of Tajikistan’s health reform agenda to achieve universal health coverage includes improved access to high-quality health care for the entire population and more efficient use of public resources. The recently adopted National Health Strategy (Strategy for the Healthcare of the Population of the Republic of Tajikistan, 2021–2030) follows global evidence and recommendations, and builds on expanding primary health care. To implement the strategy, Tajikistan needs to increase considerably public funding for health and allocate resources to where they will have the most effect. Currently, budget resources for primary health care are lagging behind, and are unevenly distributed across the country, resulting in unjust gaps in health care access. Consequently, there are unjustified differences in health care utilization.This report describes, analyses and compares alternative opportunities to increase budgetary space for health, in particular resources for primary health care.

Impact of the Covid-19 pandemic on primary care utilization: evidence from Sweden using national register data.

OBJECTIVE: To analyze changes in primary care utilization as a result of the Covid-19 pandemic. Swedish national register data from 2019 to 2020 on utilization of services were used to compare overall utilization levels and across types of contacts and patient groups. A specific objective was to assess the extent to which remote types of patient consultations were able to compensate for any observed fall in on-site visits. Data were stratified by sex and age to investigate any demographic pattern. RESULTS: Findings show significant reductions in overall utilization of services as the pandemic occurred in the first quarter of 2020. On-site visits fell during the first wave of the pandemic and rebounded thereafter. Patients over 65 years of age appear to have reduced utilization to a larger extent compared with younger groups. Simultaneously, remote contacts increased from around 12% before the pandemic to 17% of the total number of consultations. However, the net effect of changes in service utilization suggests an overall reduction of around 12 percent in the number of primary care consultations as a result of the pandemic. No differences between men and women were observed. Further research will continue to monitor changes in primary care utilization as the pandemic continues.

Study protocol: effects, costs and distributional impact of digital primary care for infectious diseases-an observational, registry-based study in Sweden.

INTRODUCTION: The ability to provide primary care with the help of a digital platform raises both opportunities and risks. While access to primary care improves, overuse of services and medication may occur. The use of digital care technologies is likely to continue to increase and evidence of its effects, costs and distributional impacts is needed to support policy-making. Since 2016, the number of digital primary care consultations for a range of conditions has increased rapidly in Sweden. This research project aims to investigate health system effects of this development. The overall research question is to what extent such care is a cost-effective and equitable alternative to traditional, in-office primary care in the context of a publicly funded health system with universal access. Three specific areas of investigation are identified: clinical effect; cost and distributional impact. This protocol describes the investigative approach of the project in terms of aims, design, materials, methods and expected results. METHODS AND ANALYSIS: The research project adopts a retrospective study design and aims to apply statistical analyses of patient-level register data on key variables from seven regions of Sweden over the years 2017-2018. In addition to data on three common infectious conditions (upper respiratory tract infection; lower urinary tract infection; and skin and soft-tissue infection), information on other healthcare use, socioeconomic status and demography will be collected. ETHICS AND DISSEMINATION: This registry-based study has received ethical approval by the Swedish Ethical Review Authority. Use of data will follow the Swedish legislation and practice with regards to consent. The results will be disseminated both to the research community, healthcare decision makers and to the general public.

Utilization of digital primary care in Sweden: Descriptive analysis of claims data on demographics, socioeconomics, and diagnoses.

OBJECTIVE: As digital technologies for health continue to develop, the ability to provide primary care services to patients with new symptoms will grow. In Sweden, two providers of digital primary care have expanded rapidly over the past years giving rise to a heated debate with clear policy implications. The purpose of the study is to present a descriptive review of digital primary care as currently under development in Sweden. METHODS: Descriptive analysis of national coverage data on the utilization of digital care by sex, age, place of residence, socioeconomic status, and most common diagnoses. The data are compared with samples of corresponding data on traditional, office-based primary care, out-of-hours care, and on non-emergency telephone consultations to obtain a comparative analysis of digital care. RESULTS: Digital primary care in Sweden has increased rapidly over the past two years. Currently, more than 30,000 digital consultations are made per month, equivalent to around two percent of all physician-led primary care. Digital care differs in some ways to that of traditional care as users are generally younger and seek for different conditions compared with office-based primary care. Digital care is also similar to traditional care as utilization is higher in metropolitan areas compared with rural areas. Similar to general health care use, there is a negative correlation between use of digital care and socioeconomic status. User profiles by age and sex of digital care are also similar to those of out-of-hours care and non-emergency telephone medical consultations. CONCLUSIONS: By providing a detailed description of the development of digital primary care the study contributes to a growing understanding of the contributions that digital technologies can make to health care. Based on current trends digital primary care is likely to continue to increase in frequency over the coming years. As technologies develop and the public becomes more familiar to interacting with medical providers over the Internet also the scope of digital care is likely to expand. As the provision of digital primary care expands across Europe and beyond, policy makers will need to develop regulating capacities to ensure its safe, effective and equitable integration into existing health systems.

The 2015 National Cancer Program in Sweden: Introducing standardized care pathways in a decentralized system.

Starting in 2015, the Swedish government has initiated a national reform to standardize cancer patient pathways and thereby eventually speed up treatment of cancer. Cancer care in Sweden is characterized by high survival rates and a generally high quality albeit long waiting times. The objective with the new national program to standardize cancer care pathways is to reduce these waiting times, increase patient satisfaction with cancer care and reduce regional inequalities. A new time-point for measuring the start of a care process is introduced called well-founded suspicion, which is individually designed for each cancer diagnosis. While medical guidelines are well established earlier, the standardisation is achieved by defining time boundaries for each step in the process. The cancer reform program is a collaborative effort initiated and incentivized by the central government while multi-professional groups develop the time-bound standardized care pathways, which the regional authorities are responsible for implementing. The broad stakeholder engagement and time-bound guidelines are interesting approaches to study for other countries that need to streamline care processes.

A literature review of the regional implementation of the central Swedish government's health care reforms on choice and privatization.

The introduction in 2010 of the Freedom of Choice Act represents one of the most far-reaching reforms of the Swedish health system. While it is mandatory for the regional counties to introduce choice plans for primary care it is voluntary for ambulatory specialist services. The voluntary nature of the regulations for the latter types of care generates a potential gap between the central government's reform attempts and the regional implementation of the plans. We review the regional implementation of this reform with respect to specialist services from a political economy perspective. Data on the scope of implementation show that counties of the same political ideology as the central government have introduced the most choice plans for specialist care. In particular, counties ruled by right-wing majorities have introduced the Choice Act to a considerably larger extent than left-wing counties. This creates a highly uneven situation across the various parts of the country, possibly at odds with the basic premises of the country's health law of equal access to care. The introduction of choice plans forms part of a decidedly contentious set of issues that are high on the political agenda of Sweden. The nature and impacts of these reforms are also a concern to the general public and the broader industry. Considerably more rigorous analyses will be needed to assess the impact on key policy parameters such as overall system efficiency and equitable access to services as a result of these changes to the health care markets.