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ABSTRACT  BACKGROUND: Access to medicine is a basic human right and one of the fundamentals of an efficient healthcare system. Therefore, many countries have developed different models to ensure that their citizens have access to affordable and good quality medicines. According to the Swedish reimbursement model, all patients receive free medicines when passing a threshold of 2400 SEK (Year 2022) of co-payment. However, providing free access to medicines without co-payment while at the same time avoiding overuse is a challenge.   AIM: The main aims of this study were to describe the proportion of patients reaching the threshold for no co-payment and to investigate if there is an increase in the amount of dispensed prescription only medications after reaching the threshold within the Swedish reimbursement model.  METHOD: A retrospective cross-sectional registry-based study was conducted using data on all dispensed prescriptions in Sweden during the period 2012-2017. The proportion of patients reaching the threshold was described annually by age and sex. Volumes of drugs dispensed measured in DDD were assessed for all major ATC 2nd level groups three month before and three months after patients reached the threshold, respectively.  RESULT: A total of 32,4 Million persons purchased prescription medicines during the period. One third of them (33%) reached the threshold and utilize the benefit of free cost. On average a 30% increase in volumes of dispensed medications were observed when comparing dispensing some therapeutic groups before and after the threshold was reached. CONCLUSION: Access to quality assured medicines is a key factor in determining the overall quality and equity of a healthcare system. However, it is important to ensure the balance between cost, affordability, and rational use. This study showed that 33% of all patients reach the threshold for free medicines annually with no gender difference and indicated that some patients purchase more drugs after reaching the threshold. Further studies are needed to assess whether this is rational or not.

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Objectives Three objectives were to compare: 1) treatment success; 2) healthcare resource uses; and 3) out-of-pocket (OOP) expenditures, indirect costs, and health-related quality of life (HRQoL) associated with pharmaceutical care, home visit, and modified DOT in three referral hospitals in Songkhla province, Thailand. Methods Project 1&2 were retrospective cohort study collecting data from 1,398 pulmonary TB patients who started treatment between October 2010 and September 2013. Project 3 was a prospective study collecting data from 104 pulmonary TB patients who started treatment between January and May 2014. The propensity score matching and generalized linear models (GLMs) were used to compare the outcomes associated with three supervision approaches by adjusting for baseline characteristics. Results Project1: The differences in treatment success rate were not statistically significant when comparing pharmaceutical care with either home visit (success rate: 92.76% versus 94.74%) or modified DOT (success rate 93.37% for both). Project2: The mean direct healthcare costs to public payer were $519.96 (95% confidence interval (CI): $437.31 to $625.58) for pharmaceutical care, $1,020.39 (CI:$911.13 to $1,154.11) for home visit, and $887.79 (CI:$824.28 to $955.91) for modified DOT. Project3: Mean OOP expenditures were $907.56 (CI:$603.80 to $1,269.41), $148.47 (CI:$109.49 to $194.89), and $95.35 (CI:$69.11 to $129.63), while the indirect costs were $1,925.68 (CI:$922.06 to $3,284.94), $2,393.66 (CI:$1,435.01 to $3,501.98), and $833.33 (CI:$453.87 to $1,263.45), for those receiving pharmaceutical care, home visit, and SAT, respectively. Mean health utility scores at the baseline and the end of treatment were 0.679 and 0.830, 0.713 and 0.905, and 0.708 and 0.913 for the patients receiving pharmaceutical care, home visit, and SAT, respectively. Conclusion Pharmaceutical care is clinically and economically effective compared with the other strategies studied. A large-scale prospective study is warranted to strengthen evidence to support policy making in TB management in Thailand. / Thesis / Doctor of Philosophy (PhD)

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Background and Objective: According to the guidelines for diabetic care in Gotland, SGLT2-inhibitors and GLP-1-analogues are recommended as an add-on treatment for when metformin in monotherapy, exercise and diet recommendations are insufficient. The aim of this study was to gain a better understanding of the effect of SGLT2-inhibitors and GLP-1-analogues on HbA1c and weight changes in patients with type II diabetes in Gotland. In addition, an overview of respective antidiabetics prescriptions in patients from Wisby Söder Health Center was performed. Study design: A retrospective quantitative study with data from three health centers in Gotland. The study population included diabetes type II patients who were prescribed SGLT-inhibitors or GLP-1-analogues during the period 2018-06-30 to 2020-06-30. This study collected data from Wisby Söder Health Center which further was used for the compilation of data from two previous student projects performed at Visby Norr and Visborg Health Center. Results were presented descriptively, a linear regression-analysis and ANOVA-test was performed. Setting: The study was conducted at Visborg, Visby Norr and Wisby Söder Health Center. Main outcome measures: The primary outcome was the change in HbA1c and weight changes as a secondary outcome. Another objective was to identify the proportion of patients with insufficient treatment defined as <10 mmol/mol HbA1c-reduction with either drug.  Results: In total, 134 patients with SGLT2-inhibitors and 182 patients with GLP-1-analogues were included. The mean HbA1c-reduction for SGLT2-inhibitor was 11 mmol/mol (±13,5 95% KI 6,9-11,2) and for GLP-1-analogues 12 mmol/mol (±14,5 95% KI: 6,9-11,1). For each drug the mean weight reduction was 3 kg (±3). There was no correlation between age and HbA1c-changes.   Conclusion: In conclusion, similar HbA1c and weight reductions were achieved with the respective drugs as in previous studies. However only about 50% of the population achieved a HbA1c-decrease with >10 mmol/mol. This indicates that further measures might need to be taken to optimize diabetes care in Gotland.