Person-centred, integrated and pro-active care for multi-morbid elderly with advanced care needs: a propensity score-matched controlled trial.

BACKGROUND: Person-centred care (PCC) focusing on personalised goals and care plans derived from "What matters to you?" has an impact on single disease outcomes, but studies on multi-morbid elderly are lacking. Furthermore, the combination of PCC, Integrated Care (IC) and Pro-active care are widely recognised as desirable for multi-morbid elderly, yet previous studies focus on single components only, leaving synergies unexplored. The effect of a synergistic intervention, which implements 1) Person-centred goal-oriented care driven by "What matters to you?" with 2) IC and 3) pro-active care is unknown. METHODS: Inspired by theoretical foundations, complexity science, previous health service research and a patient-driven evaluation of care quality, we designed the Patient-Centred Team (PACT) intervention across primary and secondary care. The PACT team collaborate with the patient to make and deliver a person-centred, integrated and proactive multi-morbidity care-plan. The control group receives conventional care. The study design is a pragmatic six months prospective, controlled clinical trial based on hospital electronic health record data of 439 multi-morbid frail elderly at risk for emergency (re) admissions referred to PACT and 779 propensity score matched controls in Norway, 2014-2016. Outcomes are emergency admissions, the sum of emergency inpatient bed days, 30-day readmissions, planned and emergency outpatient visits and mortality at three and six months follow-up. RESULTS: The Rate Ratios (RR) for emergency admissions was 0,9 (95%CI: 0,82-0,99), for sum of emergency bed days 0,68 (95%CI:0,52-0,79) and for 30-days emergency readmissions 0,72 (95%CI: 0,41-1,24). RRs were 2,3 (95%CI: 2,02-2,55) and 0,9 (95%CI: 0,68-1,20) for planned and emergency outpatient visits respectively. The RR for death at 3 months was 0,39 (95% CI: 0,22-0,70) and 0,57 (95% CI: 0,34-0,94) at 6 months. CONCLUSION: Compared with propensity score matched controls, the care process of frail multi-morbid elderly who received the PACT intervention had a reduced risk of high-level emergency care, increased use of low-level planned care, and substantially reduced mortality risk. Further study of process differences between groups is warranted to understand the genesis of these results better. TRIAL REGISTRATION: ClinicalTrials.gov (identifier: NCT02541474 ), registered Sept 2015.

A cost-minimization analysis of a realtime teledermatology service in northern Norway.

Realtime teledermatology has been a routine service provided by the University Hospital of Tromsø to a primary-care centre in Kirkenes since 1989. The cost of the teledermatology service was compared with the costs of three alternative methods of treatment for the patients. The first was a combination of a visiting service and patient travel to hospital. The second was patient travel to the nearest secondary-care centre. The third was a locally employed dermatologist. At the actual 1998 workload of 375 patients, the total cost of teledermatology was NKr470,780, while the three alternatives cost NKr880,530, NKr1,635,075 and NKr958,660, respectively. Analysis of the unit costs showed that the realtime teledermatology service, including local phototherapy, was less costly than the three alternatives for annual workloads above 195 patients per year. A sensitivity analysis showed that the results were robust to changes in the assumptions about the cost structure.

[Will the use of still image electronic referrals save costs?]. / Vil bruk av stillbildehenvisninger vaere kostnadsbesparende?

BACKGROUND: The use of still images in an electronic referral makes it possible for patients with uncomplicated skin disorders to receive treatment at their local health clinic by their own physician. The aim of this study was to analyse whether investing in technology to forward still images via telemedicine is cost-effective and to assess how many municipalities in the counties of Troms and Finnmark that have a sufficient workload to reach this requirement. MATERIAL AND METHODS: The additional costs of using still images were compared to patient travel costs to the University Hospital of Tromsø. RESULTS: The results showed that whether the use of still image telemedicine is cost-effective or not, depends on distance and annual workload. Given the assumption in this study, 18 out of 44 municipalities have a sufficient number of patients with a dermatological problem to make telemedicine cost-effective. INTERPRETATION: Less than half of the municipalities in the two northernmost counties have an efficiency potential in using still images. However, telemedicine may be justified because it save time for patients and it increases equal access to care.

An economic analysis of teleconsultation in otorhinolaryngology.

A cost comparison of three different methods of providing consultations for ear, nose and throat (ENT) problems was carried out. The study was based on the delivery of ENT examination and treatment to a small primary-care centre without an ENT specialist in northern Norway. The three alternatives evaluated were teleconsultation, a visiting specialist and patient travel to the nearest secondary-care centre. Patient travel was cheaper for patient workloads below 56 per year. For patient workloads above 56 and below 325 patients per year teleconsultation was the cheapest alternative. Above 325 patients per year, the visiting specialist service cost less than either teleconsultation or patient travel. Transfer of medical skills from the specialist to the general practitioner was also accounted for, separately from the main cost calculation. Teleconsultation then became cost-effective for patient workloads above 52 patients per year.

An economic analysis of teleradiology versus a visiting radiologist service.

An economic analysis of the teleradiology service provided by a university hospital to a local hospital without radiologists was carried out. The average workload at the local hospital was 6000 patients (8000 examinations) per year. In these circumstances teleradiology cost NKr108 per patient, in comparison with NKr178 per patient for the visiting radiologist service which had previously been provided. The total cost of the teleradiology service amounted to NKr646,900 per year; in comparison the visiting radiologist service cost NKr1,069,000 per year. Calculations showed that for teleradiology to be cheaper, the workload had to exceed 1576 patients per year. A sensitivity analysis showed that assuming a shorter equipment lifetime, for instance four years rather than six years, made the threshold value 2320 patients per year instead of 1576.

Videoconferencing in psychiatry: a survey of use in northern Norway.

A survey of the use of videoconferencing in mental health care was carried out in northern Norway. A questionnaire was distributed to all user institutions in northern Norway at the same time that ISDN became available, in mid-1995. The questionnaire completion rate for locations recorded as participants in videoconferencing sessions was 62%. Within six months, a total of 1028 persons had participated in 140 videoconferencing sessions from 35 institutions. The purposes of videoconferencing included meetings (50%), supervision, training and teaching (31%), clinical consultations (14%) and tests or demonstrations (5%). The alternative forms of contact which videoconferencing replaced included travel (59%), no contact (25%), telephone (14%), and mail or fax (2%). No problems were reported in 55% of the sessions; in 19% there were audio problems, in 14% there were picture problems, in 5% attempts to connect failed and in 5% disconnection occurred. The majority of users (87%) reported that they were satisfied or very satisfied with the facility; 8% were uncertain and 5% were less satisfied or totally dissatisfied. Continued surveying will provide longitudinal data on the diffusion of telepsychiatry in northern Norway.