Health Technology Assessment is an important factor for decision making in the healthcare sector in Sweden. It helps to curtail the rising costs associated with the healthcare sector and aids in the efficient allocation of scarce public health resources. This thesis investigates the cost-effectiveness and the effectiveness in general of two health technologies, addressing the following research objectives: i) assessing the cost-effectiveness of mobile health (mHealth) interventions designed for older adults diagnosed with mild cognitive impairment, and ii) assessing the effectiveness of peritoneal dialysis (PD) treatment on labor market outcomes in comparison with institutional hemodialysis (IHD) treatment in Swedish settings. Study I and Study II are related to the first research objective. In Study I, we summarized and critically assessed the current evidence on the cost-effectiveness of mHealth interventions focusing on older adults; we found some evidence supporting the cost-effectiveness of these interventions. In Study II, we conducted a within-trial cost-effectiveness analysis of the software application Support, Monitoring and Reminder Technology for Mild Dementia (SMART4MD) from a healthcare perspective for a period of six months. A total of 345 Swedish dyads (MCI patient and informal caregiver) participated in this study. For a short time period of six months, we found that SMART4MD is not cost-effective for MCI patients (statistically insignificant); however, a trend was observed that indicated that it might be cost-effective for informal caregivers, although results remained statistically insignificant (p > 0.05). Study III is related to the second research objective. In Study III, we investigated the effect of PD on labor market outcomes (employment rate, work income, and disability pension) in comparison to IHD. We found that PD is associated with a treatment advantage over IHD in terms of increased employment, work income, and reduced disability pension in the Swedish population after controlling for non-random selection for the treatment.

Modern Technologies in Medicine and Law Abstract This thesis deals with the application of modern technologies in medicine from the perspective of law. The primary aim of this work is to analyse the given provisions of the Civil Code, Act on Health Services and Act on Medical Devices, and also to determine whether the current legislation represents a suitable legal framework able to respond to the implementation of modern technology in the healthcare sector. In connection with this analysis, author presents possibilities of legislative changes that would respond to these modern technologies. The work inter alia deals with the question of whether the use of some of these technologies within the provision of healthcare services can be considered compliant with the principle of lege artis. In the first chapter, the reader is introduced to the topic of the thesis. This chapter defines the basic terms and presents an overview of the legislation related to the chosen topic. The second chapter represents a main part of the thesis, where author deals with the topic of artificial intelligence. In this chapter, the reader is acquainted with the term of artificial intelligence and the definition of its legal status. Subsequently, author evaluates whether the current legislation constitutes appropriate legal frameworks...

Utvecklingen av digital vård sker i en snabb takt vilket bland annat informations- och kommunikationsteknik (IKT) och Covid-19 pandemin tillsammans ligger till grund för. Litteratur inom området lyfter att digital vård ökar arbetsbelastningen inom vården då det bland annat sätter högre krav på vårdpersonals tekniska kunskap och medicinska bedömning. Syftet med denna studie är att bidra med kunskap om vårdpersonals upplevelser av användningen av videosamtal i digitala patientmöten. Vi har använt en kvalitativ forskningsansats grundad i litteratur som behandlar digital vård där åtta semistrukturerade intervjuer med legitimerad vårdpersonal genomförts. I analysen av dessa åtta intervjuer framkom det fyra teman med tillhörande subteman, nämligen flexibilitet (individanpassad vård och digifysiskt arbetssätt), tillgänglighet (jämlik vård och tidsschema), effektivitet (arbetsbelastning och tid & rum) och teknik (personlig inställning, användning av systemen och digital kvalitet). De fyra temana har delats in i tre kategorier av upplevelser: moraliskt ansvar, dynamisk tidsbalans och mottaglighet. Slutsatsen som denna studie drar är att vårdpersonal inte upplever att fysisk eller digital vård är optimal som solitär, utan att digifysisk vård är det mest gynnsamma alternativet för samhället i stort. Det vill säga för såväl individ i form av både patient och vårdpersonal som för organisationer. Studien bidrar därför med kunskapen om att digital och fysisk vård kompletterar varandra och att systemen bör sammanflätas för att en sådan kombination skulle vara optimal. / The development of digital healthcare is happening at a rapid pace which Information and Communication Technologies (ICT) along with the Covid-19 pandemic is the main reason for. Existing literature highlights that digital care increases the workload within health care because the demand and requirements on the healthcare workers technical knowledge and medical assessment is elevated. The purpose of the study is to contribute with knowledge of health care workers experiences in the use of video consultations in digital healthcare. This was done through a qualitative research approach based on existing litteratur where eight semi structured interviews with legitimised healthcare workers were performed. The analysis of the interviews resulted in four themes with sub themes, which were flexibility (individualised care and digiphysic work method), accessibility (equal care and time schedule), efficiency (workload and time & space) and technology (personal attitude, use of systems and digital quality). The themes have been categorised into three categories of experiences: moral responsibility, dynamic time balance and receptiveness. In conclusion the health care workers do not experience either physical care or digital care to be optimal individually, but that a combination of the two would be the most favourable alternative for society as a whole. That is, for both the individual in the form of both patient and health care workers as well as health organisations. The study therefore contributes with the knowledge that digital and physical care complements each other and that the systems should be intertwined for such a combination to be possible and optimised.

Bakgrund: Dietary Approaches to Stop Hypertension (DASH) är en väletablerad icke-farmakologisk behandling vid hypertoni men används sällan inom traditionell hälso-och sjukvård på grund av tids- och resursbrist. Digitala metoder kan vara bättre lämpade för att ge långsiktigt stöd. Denna studie är den första digitala kostinterventionen med DASH-kost i en total digital vårdmiljö. Syfte: Syftet med studien är att undersöka följsamhet till DASH-kost samt upplevelse av digital kostbehandling vid hypertoni. Material och metod: Studien har en experimentell design och utgick från den digitala vårdgivaren Blodtrycksdoktorns plattform. Nitton patienter med lätt förhöjt blodtryck fick digital kostbehandling utifrån DASH-kost under 8 veckor utöver standardbehandling. Videosamtal i kombination med asynkron textkommunikation användes som kommunikationsverktyg. Kostförändring mättes via livsmedelsfrekvensformulär (FFQ) före och efter behandling och sammanställdes i ett DASH-index. Patientupplevelse mättes via enkät efter behandling. Studien undersökte även förändring av vikt, BMI, midjemått och blodtryck. Statistisk analys genomfördes med Parat t-test samt Wilcoxons ranksummetest. Resultat: DASH-index förbättrades med 1,4 poäng (p = <0,001). Patienterna hade i genomsnitt haft diagnosen hypertoni under 6 år ± 8 SD (median 2 år) där endast 2 av 19 tidigare fått kostråd för hypertoni. Patienterna hade överlag en positiv upplevelse av digital kostbehandling. Vikt och BMI minskade med 1,9 kg (p = <0,001) respektive 0,7 kg/m2 ( p = <0,001). Midjemåttet minskade med 3,2 cm för manliga patienter (p = 0,007) och 4 cm för kvinnliga patienter (p = 0,027). Systoliskt blodtryck (SBT) minskade med 8,7 mmHg (p = <0,001) och diastoliskt blodtryck (DBT) med 4,6 mmHg (p = 0,004). Slutsats: Den 8 veckor långa digitala kostinterventionen förbättrade kostvanor hos patienter med hypertoni samt ledde till minskad vikt, BMI, midjemått och blodtryck. Patientupplevelse av behandlingen var god. Digital kostbehandling kan utgöra ett alternativ till traditionell kostbehandling för patienter med hypertoni. / Background: Dietary Approaches to Stop Hypertension (DASH) is a well-established non-pharmacological treatment for hypertension but is rarely used in traditional health care due to lack of time and resources. Digital methods may be better suited to provide long-term support. This study is the first digital nutrition intervention with DASH diet in a total digital health care environment. Aim: The purpose of the current study is to investigate adherence to DASH diet and self-reported experience of a digital nutrition intervention for patients with hypertension. Material and methods: The study has an experimental design and was based on the platform of the digital healthcare provider “Blood Pressure Doctor”. Nineteen patients with primary hypertension received digital nutrition therapy based on the DASH diet for 8 weeks in addition to standard care. Video calls in combination with asynchronous text communication were used as communication tools. Dietary change was measured by food frequency questionnaire (FFQ) at baseline and after treatment and compiled in a DASH index. A questionnaire was used to assess patient experience. Secondary outcomes were changes in body weight, BMI, waist measurement and blood pressure. Statistical analysis was performed with Pared t-test and Wilcoxon signed rank test. Results: DASH index improved by 1,4 points (p = <0,001). The patients had on average been diagnosed with hypertension for 6 years ± 8 SD (median 2 years) where only 2 of 19 had previously received dietary advice for hypertension. The patients generally had a positive experience of the digital nutrition intervention. Body weight and BMI decreased by 1,9 kg (p = <0,001) and 0,7 kg / m2 (<0,001), respectively. Waist decreased by 3,2 cm for male patients (p = 0,007) and 4 cm for female patients (p = 0,027). Systolic blood pressure (SBP) decreased by 8,7 mmHg (p = <0,001) and diastolic blood pressure (DBT) by 4,6 mmHg (p = 0,004). Conclusion: The 8-week digital nutrition intervention improved dietary habits, body weight, BMI, waist and blood pressure of patients with hypertension. Patients were overall satisfied with the treatment. Digital nutritional therapy can be an alternative to traditional nutritional therapy for patients with hypertension.

Background: Recent studies showed that the safety and benefit of early intravenous (IV) thrombolysis on favourable outcomes in acute ischemic stroke are also seen in the elderly. Furthermore, it has shown that age increases times for pre- and in-hospital procedures. We aimed to assess the applicability of these findings to telestroke. Methods: We retrospectively analysed 542 of 1659 screened consecutive stroke patients treated with IV thrombolysis in our telestroke network in East-Saxony, Germany from 2007 to 2012. Outcome data were symptomatic intracranial hemorrhage (sICH) by ECASS-2-criteria, survival at discharge and favourable outcome, defined as a modified Rankin scale (mRS) of 0–2 at discharge. Results: Thirty-three percent of patients were older than 80 years (elderly). Being elderly was associated with higher risk of sICH (p¼0.003), less favourable outcomes (p¼0.02) and higher mortality (p¼0.01). Using logistic regression analysis, earlier onsetto-treatment time was associated with favourable outcomes in not elderly patients (adjusted odds ratio (OR) 1.18; 95% CI 1.03–1.34; p¼0.01), and tended to be associated with favourable outcomes (adjusted OR 1.13; 95% CI 0.92–1.38; p¼0.25) and less sICH (adjusted OR 0.88; 95% CI 0.76–1.03; p¼0.11) in elderly patients. Age caused no significant differences in onset-to-doortime (p¼0.25), door-to-treatment-time (p¼0.06) or onset-to-treatment-time (p¼0.29). Conclusion: Treatment time seems to be critical for favourable outcome after acute ischemic stroke in the elderly. Age is not associated with longer delivery times for thrombolysis in telestroke.

Objetivo: Evaluar la validez y confiabilidad de la adaptación del test Short Physical Performance Battery (SPPB) para su aplicación virtual en adultos mayores peruanos. Materiales y métodos: Este estudio es observacional de tipo instrumental. Se encuestó a adultos mayores de 60 años para evaluar su rendimiento físico. Esta variable se midió a través de la adaptación del Short Physical Performance Battery (SPPB); donde el resultado final iba de 0 a 12 puntos y se clasificó por persona frágil, pre frágil y normal. La adaptación del test SPPB se realizó en las indicaciones para adecuarlas a su aplicación virtual y se validó el contenido mediante evaluación por expertos. Resultados: Se reclutaron 112 adultos mayores pero se evaluaron a 96 ya que, se excluyeron a adultos mayores con diagnóstico de artritis, antecedentes de fractura menores a un año, no contar con internet y con cuidador el día de la evaluación. La adaptación del SPPB obtuvo promedios similares por ambos evaluadores; además, se determinó la confiabilidad mediante el coeficiente kappa obteniendo un 0.87 en la subprueba de equilibrio, 0.84 en velocidad de marcha y 0.64 en levantarse de la silla. El resultado general del SPPB llega a un coeficiente de kappa de 0.86 y un acuerdo de 92%, se obtuvieron mediante un análisis inter-evaluadores con un IC de 0.83-0.92. Conclusión: La adaptación del test Short Physical Performance Battery es válida y confiable para su aplicación virtual en adultos mayores peruanos. / Objective: To evaluate the validity and reliability of the adaptation of the Short Physical Performance Battery (SPPB) test to its virtual application in Peruvian elderly people. Materials and methods: This is an observational study of an instrumental type. Adults over 60 years old were surveyed in order to evaluate their physical performance. This variable was measured through the adaptation of the Short Physical Performance Battery (SPPB); where the final result ranged from 0 to 12 points and it was classified by normal, pre-frail, and frail people. The adaptation to the SPPB test was carried out in the indications to adequate them to its virtual application and its content was validated through evaluations by experts. Results: 112 elderly people were recruited but 96 were evaluated, since elderly people without a rheumatoid arthritis diagnosis were included, without a medical record of fractures in less than a year, having internet access, and with a caregiver the evaluation day. The adaptation of the SPPB got similar results by both evaluators. Besides, the reliability was determined by using the Cohen’s Kappa coefficient obtaining 0.87 in the balance sub-test, 0.84 in walking speed, and 0.64 in getting up from the chair. The general result of the SPPB reaches a Kappa coefficient of 0.86 and an agreement of 92% was obtained through inter-rater reliability (IRR) with a Confidence Interval (CI) of 0.83-0.92. Conclusion: The adaptation of the Short Physical Performance Battery test is valid and reliable for its virtual application in Peruvian elderly people. / Tesis

The introduction of welfare markets in publicly financed healthcare system has together with digital innovation of healthcare delivery led to a rapid growth of direct-to-consumer telemedicine services. In Sweden, the rise of such digital doctors has sparked a debate and there are indications that these developments might affect the overreaching goals of Swedish healthcare delivery on equal terms and according to need. This thesis examines the emergence of the new digital healthcare market and the political debate surrounding these developments, in order to answer the overreaching question of what these developments mean for equity in health in the Swedish healthcare system. This is done by describing developments on the digital healthcare market in Sweden and by conducting an idea analysis of the political parties’ views on these developments. Findings indicate that healthcare providers have great influence on the digital healthcare market in Sweden at the expense of public actors. Results from the idea analysis shows that political parties mainly discuss health equity in relation to the digital healthcare market in line with social or liberal egalitarian ideas of health equity.

Background. Diabetes requires significant disease management, patient-provider communication, and interaction between patients, family members, caregivers, and care teams. Emerging patient-facing technologies, such as cellular-enabled glucose meters, can facilitate additional care support and improve diabetes self-management. This study evaluated patient acceptability, feasibility, and efficacy of a diabetes care support program facilitated by cellular-enabled glucose meters. Methods. A two-phase study approach was taken. Get In Touch – Phase 1 (GIT-1) was a 1-month pilot involving patients with type 1 and type 2 diabetes. Get In Touch – Phase 2 (GIT-2) was a 12-month randomized controlled crossover trial involving patients with poorly-controlled type 2 diabetes. Results from GIT-1 and preliminary results from GIT-2 are presented. Results. GIT-1 participants with type 1 (n=6) and type 2 (n=10) diabetes reported the intervention and cellular-enabled glucose meter were easy to use and useful while identifying potential areas of improvement. GIT-2 participants in both the intervention (n=60) and control (n=60) groups saw significant improvements in treatment satisfaction and A1c change, with intervention participants experiencing slightly greater improvements in each after 6 months (p=0.09 and p=0.16, respectively) compared to control participants. Conclusions. Patients reported favorable acceptability of the intervention. Preliminary results from a randomized trial demonstrated potential of intervention to improve patient-reported and physiological health outcomes. Future studies should evaluate feasibility and efficacy over a longer period of time, with a greater number of participants, and targeting different populations of patients with diabetes. Provider perspectives and changes in provider behavior, clinical work flow, and caregiver burden should also be assessed.

La presente tesis propone el desarrollo de un sistema prototipo de estetoscopio digital para ser usado en consultas médicas remotas, utilizando transmisión por la red celular (GSM) e Internet, con la finalidad de brindarle a los profesionales en la salud una herramienta con la cual puedan seguir realizando sus consultas cotidianas evitando el contacto directo con el paciente, por ende, previniendo el contagio de una enfermedad infecciosa. Por ello, el presente trabajo se divide en tres partes: la adquisición y transmisión de las señales de auscultación, el servidor Web y el software de control. El primer paso que se debe realizar es la adquisición de la señal acústica proporcionada por el estetoscopio. Las señales ingresan al controlador para su grabación y ser transmitidas vía Internet al servidor Web. Además, previo a la grabación de las señales, el médico, utilizando el software de control, podrá escuchar la señal acústica en tiempo real mediante una llamada a celular para indicar al paciente la correcta posición del estetoscopio. En el servidor se encuentran las grabaciones ordenadas en carpetas con los datos del paciente, dichos archivos son descargables y reproducibles. El método de validación se realizó con una encuesta y pruebas del prototipo con diferentes médicos. Los resultados obtenidos demostraron que el prototipo brinda una buena calidad de los sonidos auscultados, siendo así útil para poder realizar un diagnóstico preliminar certero de manera remota. / The present thesis proposes the development of a digital stethoscope prototype system to be used in remote medical attentions using the celular network transmittion (GSM) and Internet, in order to provide to health professionals a tool which they can keep making their attentions avoiding physical contact with the patient. Thus, preventing the spread of an infectious disease. Therefore, the present work is divided in three parts: the acquisition and transmisión of auscultation signals, the Web server and the software. The first step to take is the acoustic signal acquisition provided by stethoscope. Signals enter the controller for recording and transmitted via Internet to Web server. Also, prior to recording the signals, the doctor, using the software, can hear the eliminate signals in real time using the call in order to indicate the correct position of stethoscope to patient. The recordings are stored on the Web server arranged in folders with data patient, the files are downloadable and playable. The validation method was performed using an inquest and testing prototype with different doctors. The results obtained showed that prototype provides a good quality of auscultated sounds, thus being useful to be able to carry out an accurate preliminary diagnosis remotely. / Tesis

The wide usage of smartphones makes them an interesting and potential medical device. Given that smartphone cameras have a sufficiently high quality - some of the medical photography done at health care facilities could be done telemedically and by non-medically educated per- sons. Therefore a research of the quality of the photos taken with smartphone cameras has been done. This thesis presents guidelines regarding how inexperienced persons could take high qualitative medical photos with a smartphone. This thesis includes a review of current guidelines within medical photography. A compari- son between two popular smartphones and a professional medical camera has been done - where possibilities and limitations in smartphone cameras have been identified. In order to evaluate the sharpness and the color temperature representation in the photos taken with smartphones, an experiment with realistic lighting and easy accessible color-calibration cards has been done. The execution and the achieved result have formed the basis of the proposed guidelines. The result shows that smartphone cameras are of high quality and thereby could be used as a complement to advanced medical camera equipment. With the help of the proposed guidelines inexperienced persons could acquire sufficiently good medical photos, in order to be used as diagnostic material. This thesis provides a foundation for further research and implementation within the area, with the purpose of becoming an important part of the efficiency improvement within the telemedical health care.