Tailored implementation of national recommendations on fall prevention among older adults in municipalities in Norway (FALLPREVENT trial): a study protocol for a cluster-randomised trial.

BACKGROUND: Despite substantial research evidence indicating the effectiveness of a range of interventions to prevent falls, uptake into routine clinical practice has been limited by several implementation challenges. The complexity of fall prevention in municipality health care underlines the importance of flexible implementation strategies tailored both to general determinants of fall prevention and to local contexts. This cluster-randomised trial (RCT) investigates the effectiveness of a tailored intervention to implement national recommendations on fall prevention among older home-dwelling adults compared to usual practice on adherence to the recommendations in health professionals. METHODS: Twenty-five municipalities from four regions in Norway will be randomised to intervention or control arms. Each municipality cluster will recruit up to 30 health professionals to participate in the study as responders. The tailored implementation intervention comprises four components: (1) identifying local structures for implementation, (2) establishing a resource team from different professions and levels, (3) promoting knowledge on implementation and fall prevention and (4) supporting the implementation process. Each of these components includes several implementation activities. The Consolidated Framework for Implementation Research (CFIR) will be used to categorise determinants of the implementation process and the Expert Recommendations for Implementing Change (ERIC) will guide the matching of barriers to implementation strategies. The primary outcome measure for the study will be health professionals' adherence to the national recommendations on fall prevention measured by a questionnaire. Secondary outcomes include injurious falls, the feasibility of the intervention, the experiences of the implementation process and intervention costs. Measurements will be carried out at baseline in August 2023, post-intervention in May 2024 and at a follow-up in November 2024. DISCUSSION: This study will provide evidence on the effectiveness, intervention costs and underlying processes of change of tailored implementation of evidence-based fall prevention recommendations. TRIAL REGISTRATION: The trial is registered in the Open Science Registry: https://doi.org/10.17605/OSF.IO/JQ9T5 . Registered: March 03, 2023.

Completing the time trade-off with respondents who are older, in poorer health or with an immigrant background in an EQ-5D-5L valuation study.

OBJECTIVES: To determine the effects of age, immigrant background, and poor self-reported health in a general population sample on the probability of non-completion or slow completion of the time trade-off (TTO). METHODS: We used data from an interrupted Norwegian EQ-5D-5L valuation study conducted between 2019 and 2020. All participants responded to background items, irrespective of completion. We used mixed effect logistic regression analysis to assess the effect of old age, poor health, and immigrant background on the probability of non-completion of the TTO, and, for those who completed the TTO, of slow completion times. RESULTS: First experiences from a Norwegian valuation study were that 29 (5.5%) respondents failed to complete the TTO tasks. For those reporting age over 65 years, poor health, or an immigrant background, 12% failed to complete the TTO. Adjusted odds ratios for predictors of non-completion were statistically significant (age > 65 years, 8.3; EQ-VAS ≤ 50, 3.49; immigrant background, 4.56). Being over 65 years or with an immigrant background also predicted slow completion of both the introduction and TTO tasks. CONCLUSIONS: High age, poor health, and immigrant status increased the risk of not being able to complete the TTO tasks, and of slow completion. Higher non-completion rates and increased completion times suggest that elements of the TTO may be demanding for some respondent groups, with possible implications for representativeness.

Sample Size and Model Prediction Accuracy in EQ-5D-5L Valuations Studies: Expected Out-of-Sample Accuracy Based on Resampling with Different Sample Sizes and Alternative Model Specifications.

Background. National valuation studies are costly, with ∼1000 face-to-face interviews recommended, and some countries may deem such studies infeasible. Building on previous studies exploring sample size, we determined the effect of sample size and alternative model specifications on prediction accuracy of modeled coefficients in EQ-5D-5L value set generating regression analyses. Methods. Data sets (n = 50 to ∼1000) were simulated from 3 valuation studies, resampled at the respondent level and randomly drawn 1000 times with replacement. We estimated utilities for each subsample with leave-one-out at the block level using regression models (8 or 20 parameter; with or without a random intercept; time tradeoff [TTO] data only or TTO + discrete choice experiment [DCE] data). Prediction accuracy, root mean square error (RMSE), was calculated by comparing to censored mean predicted values to the left-out block in the full data set. Linear regression was used to estimate the relative effect of changes in sample size and each model specification. Results. Results showed that doubling the sample size decreased RMSE by on average 0.012. Effects of other model specifications were smaller but can when combined compensate for loss in prediction accuracy from a small sample size. For models using TTO data only, 8-parameter models clearly outperformed 20-parameter models. Adding a random intercept, or including DCE responses, also improved mean RMSE, most prominently for variants of the 20-parameter models. Conclusions. The prediction accuracy impact of further increases in sample size after 300 to 500 were smaller than the impact of combining alternative modeling choices. Hybrid modeling, use of constrained models, and inclusion of random intercepts all substantially improve the expected prediction accuracy. Beyond a minimum of 300 to 500 respondents, the sample size may be better informed by other considerations, such as legitimacy and representativeness, than by the technical prediction accuracy achievable. Highlights: Increases in sample size beyond a minimum in the range of 300 to 500 respondents provide smaller gains in expected prediction accuracy than alternative modeling approaches.Constrained, nonlinear models; time tradeoff + discrete choice experiment hybrid modeling; and including a random intercept all improved the prediction accuracy of models estimating values for the EQ-5D-5L based on data from 3 different valuation studies.The tested modeling choices can compensate for smaller sample sizes.

Norwegian population norms for the EQ-5D-5L: results from a general population survey.

PURPOSE: To provide the first Norwegian EQ-5D-5L and EQ VAS population norms for the adult general population. METHODS: Postal survey of a random sample of 12,790 Norwegians identified through the National Registry of the Norwegian Tax Administration. Norms, weighted for Norwegian general population characteristics, are shown for the five EQ-5D-5L dimensions, EQ-5D index, and EQ VAS scores for seven age categories, females, males, and education level. RESULTS: There were 3200 (25.9%) respondents to 12,263 correctly addressed questionnaires. The EQ-5D-5L dimensions, EQ VAS, and background questions were completed by 3120 (24.6%) respondents. The mean age (SD) was 50.9 (21.7) and range was 18-97 years. The youngest age group of 18-29 years and oldest of 80 years and over had the highest (n = 691) and lowest (n = 239) number of respondents, respectively. Compared to the general population, the respondents comprised a greater number of females, younger and older ages, and had a higher education level. 32% of respondents reported no health problems on the EQ-5D-5L. From the youngest to oldest age groups, there was a general decline in health as assessed by the EQ-5D-5L. The exception was for anxiety/depression, where the youngest age groups had the poorest health. Apart from self-care, women reported poorer health than men, as assessed by the EQ-5D-5L; EQ VAS scores were similar for men and women. Higher levels of health (EQ-5D index, EQ VAS scores) were found with increasing levels of education. CONCLUSION: The population norms will improve interpretation of EQ-5D-5L and EQ VAS scores in Norwegian applications including clinical practice, clinical and health services research, and national quality registers where EQ-5D-5L is the most widely used patient-reported instrument.

Time trade-off with someone to live for: impact of having significant others on time trade-off valuations of hypothetical health states.

BACKGROUND: The TTO task involves giving up life years, i.e. living a shorter life, to avoid an undesirable health state. Despite being a hypothetical task, some respondents take other life factors into account when completing the task. This study explored the effect of having children and/or a partner on TTO valuations of hypothetical EQ-5D-5L health states in a valuation study of the general population. METHODS: The study used TTO data collected in a Norwegian EQ-5D-5L valuation study in 2019-2020, by one-to-one pc-assisted interviews following the EQ-VT protocol. We used regression modelling to determine the effect of significant others (having children or a partner) on disutility per health state from the TTO valuations. RESULTS: 430 respondents were included [mean age 43.8 (SD 15.9) years, 58% female, 48% with children, 68% with a partner, 25% with neither children nor partner]. Having children and/or a partner was associated with lowered willingness to trade life years translating to higher elicited health state utilities (p < 0.01). CONCLUSION: Having significant others, or the lack of having significant others, was associated with respondents' valuation of hypothetical health states using TTO, more so than traditional sampling variables such as age and sex. Inadequate representativeness in terms of having significant others could bias health state preference values in valuation studies.

A methodology for identifying high-need, high-cost patient personas for international comparisons.

OBJECTIVE: To establish a methodological approach to compare two high-need, high-cost (HNHC) patient personas internationally. DATA SOURCES: Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. STUDY DESIGN: We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, home-health care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries. DATA COLLECTION/EXTRACTION METHODS: Data collected by ICCONIC partners. PRINCIPAL FINDINGS: Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries. CONCLUSION: Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

Elicitation of Norwegian EQ-5D-5L values for hypothetical and experience-based health states based on the EuroQol Valuation Technology (EQ-VT) protocol.

INTRODUCTION: Norway is one of several European countries that lacks a national value set and scoring algorithm for the EuroQol five dimensions (EQ-5D). Recent studies have found differences between countries in terms of health values or preferences for health states described by instruments such as the EQ-5D. The project aims to model a national value set for the five level version of the EQ-5D based on values elicited from a representative sample of the Norwegian adult general population in terms of region, age, sex and level of education. Using a sampling strategy supporting the collection of values for both hypothetical and experienced health states, the study will have the additional aim of assessing the feasibility of collecting experience-based values in accordance with the latest EQ-5D valuation study protocol, and comparing values with those given for hypothetical health states. METHODS AND ANALYSIS: Multistage random sampling and quota-sampling will contribute to representativeness. To increase the number of valuations of experienced health states, those with less than perfect health will be oversampled, increasing the total number of interviews from 1000 to 1300-1500. The most recent EQ-5D valuation protocol will be followed which includes computer assisted face-to-face, one-to-one interviews and use of composite time trade-off and discrete choice experiments. ETHICS AND DISSEMINATION: The study has been reviewed and found to be outside of the scope of the ethics committee and thus not in need of ethical approval. The study findings will be disseminated through peer-reviewed publications, conference presentations and summaries for key stakeholders and partners in the field. The scoring algorithms will be available for widely used statistical software.

Associations between work satisfaction, engagement and 7-day patient mortality: a cross-sectional survey.

OBJECTIVE: This study examines the association between profession-specific work environments and the 7-day mortality of patients admitted to these units with acute myocardial infarction (AMI), stroke and hip fracture. DESIGN: A cross-sectional study combining patient mortality data extracted from the South-Eastern Norway Health Region, and the work environment scores at the hospital ward levels. A case-mix adjustment model was developed for the comparison between hospital wards. SETTING: Fifty-six patient wards in 20 hospitals administered by the South-Eastern Norway Regional Health Authority. PARTICIPANTS: In total, 46 026 patients admitted to hospitals with AMI, stroke and hip fracture, and supported by 8800 survey responses from physicians, nurses and managers over a 3-year period (2010-2012). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures were the associations between the relative mortality rate for patients admitted with AMI, stroke and hip fractures and the profession-specific (ie, nurses, physicians, middle managers) mean scores on the 19 organisational factors in a validated cross sectional, staff survey conducted annually in Norway. The secondary outcome measures were the mean scores with SD on the organisational factors in the staff survey reported by each profession. RESULTS: The Nurse workload (beta 0.019 (95% CI0.009-0.028)) and middle manager engagement (beta 0.024 (95% CI0.010-0.037)) levels were associated with a case-mix adjusted 7-day patient mortality rates. There was no significant association between physician work environment scores and patient mortality rates. CONCLUSION: 7-day mortality rates in hospital wards were negatively correlated with the nurse workload and manager engagement levels. A deeper understanding of the relationships between patient outcomes, organisational structure and their underlying cultural barriers is needed because they may provide a better understanding of the harm and death risks for patients due to organisational characteristics.

Hospital Variation in 30-Day Mortality for Patients With Stroke; The Impact of Individual and Municipal Socio-Demographic Status.

Background Thirty-day mortality after hospitalization for stroke is commonly reported as a quality indicator. However, the impact of adjustment for individual and/or neighborhood sociodemographic status ( SDS ) has not been well documented. This study aims to evaluate the role of individual and contextual sociodemographic determinants in explaining the variation across hospitals in Norway and determine the impact when testing for hospitals with low or high mortality. Methods and Results Patient Administrative System data on all 45 448 patients admitted to hospitals in Norway with an incident stroke diagnosis from 2005 to 2009 were included. The data were merged with data from several databases to obtain information on vital status (dead/alive) and individual SDS variables. Logistic regression models were compared to estimate the predictive effect of individual and neighborhood SDS on 30-day mortality and to determine outlier hospitals. All individual SDS factors, except travel time, were statistically significant predictors of 30-day mortality. Of the municipal variables, only the municipal variable proportion of low income was statistically significant as a predictor of 30-day mortality. Including sociodemographic characteristics of the individual and other characteristics of the municipality improved the model fit. However, performance classification was only changed for 1 (out of 56) hospital, from "significantly high mortality" to "nonoutlier." Conclusions Our study showed that those stroke patients with a lower SDS have higher odds of dying after 30 days compared with those with a higher SDS , although this did not have a substantial impact when classifying providers as performing as expected, better than expected, or worse than expected.

Postoperative wound dehiscence after laparotomy: a useful healthcare quality indicator? A cohort study based on Norwegian hospital administrative data.

OBJECTIVES: Postoperative wound dehiscence (PWD) is a serious complication to laparotomy, leading to higher mortality, readmissions and cost. The aims of the present study are to investigate whether risk adjusted PWD rates could reliably differentiate between Norwegian hospitals, and whether PWD rates were associated with hospital characteristics such as hospital type and laparotomy volume. DESIGN: Observational study using patient administrative data from all Norwegian hospitals, obtained from the Norwegian Patient Registry, for the period 2011-2015, and linked using the unique person identification number. PARTICIPANTS: All patients undergoing laparotomy, aged at least 15 years, with length of stay at least 2 days and no diagnosis code for immunocompromised state or relating to pregnancy, childbirth and puerperium. The final data set comprised 66 925 patients with 78 086 laparotomy episodes from 47 hospitals. OUTCOMES: The outcome was wound dehiscence, identified by the presence of a wound reclosure code, risk adjusted for patient characteristics and operation type. RESULTS: The final data set comprised 1477 wound dehiscences. Crude PWD rates varied from 0% to 5.1% among hospitals, with an overall rate of 1.89%. Three hospitals with statistically significantly higher PWD than average were identified, after case mix adjustment and correction for multiple comparisons. Hospital volume was not associated with PWD rate, except that hospitals with very few laparotomies had lower PWD rates. CONCLUSIONS: Among Norwegian hospitals, there is considerable variation in PWD rate that cannot be explained by operation type, age or comorbidity. This warrants further investigation into possible causes, such as surgical technique, perioperative procedures or handling of complications. The risk adjusted PWD rate after laparotomy is a candidate quality indicator for Norwegian hospitals.