Associations between outpatient care and later hospital admissions for patients with chronic obstructive pulmonary disease - a registry study from Norway.

BACKGROUND: Although chronic obstructive pulmonary disease (COPD) admissions put a substantial burden on hospitals, most of the patients' contacts with health services are in outpatient care. Traditionally, outpatient care has been difficult to capture in population-based samples. In this study we describe outpatient service use in COPD patients and assess associations between outpatient care (contact frequency and specific factors) and next-year COPD hospital admissions or 90-day readmissions. METHODS: Patients over 40 years of age residing in Oslo or Trondheim at the time of contact in the period 2009-2018 were identified from the Norwegian Patient Registry (in- and outpatient hospital contacts, rehabilitation) and the KUHR registry (contacts with GPs, contract specialists and physiotherapists). These were linked to the Regular General Practitioner registry (characteristics of the GP practice), long-term care data (home and institutional care, need for assistance), socioeconomic and-demographic data from Statistics Norway and the Cause of Death registry. Negative binomial models were applied to study associations between combinations of outpatient care, specific care factors and next-year COPD hospital admissions and 90-day readmissions. The sample consisted of 24,074 individuals. RESULTS: A large variation in the frequency and combination of outpatient service use for respiratory diagnoses (GP, emergency room, physiotherapy, contract specialist and outpatient hospital contacts) was apparent. GP and outpatient hospital contact frequency were strongly associated to an increased number of next-year hospital admissions (1.2-3.2 times higher by increasing GP frequency when no outpatient hospital contacts, 2.4-5 times higher in combination with outpatient hospital contacts). Adjusted for healthcare use, comorbidities and sociodemographics, outpatient care factors associated with lower numbers of next-year hospitalisations were fees indicating interaction between providers (7% reduction), spirometry with GP or specialist (7%), continuity of care with GP (15%), and GP follow-up (8%) or rehabilitation (18%) within 30 days vs. later following any current year hospitalisations. For 90-day readmissions results were less evident, and most variables were non-significant. CONCLUSION: As increased use of outpatient care was strongly associated with future hospitalisations, this further stresses the need for good communication between providers when coordinating care for COPD patients. The results indicated possible benefits of care continuity within and interaction between providers.

Combination of health care service use and the relation to demographic and socioeconomic factors for patients with musculoskeletal disorders: a descriptive cohort study.

BACKGROUND: Patients with musculoskeletal disorders (MSDs) access health care in different ways. Despite the high prevalence and significant costs, we know little about the different ways patients use health care. We aim to fill this gap by identifying which combinations of health care services patients use for new MSDs, and its relation to clinical characteristics, demographic and socioeconomic factors, long-term use and costs, and discuss what the implications of this variation are. METHODS: The study combines Norwegian registers on health care use, diagnoses, comorbidities, demographic and socioeconomic factors. Patients (≥ 18 years) are included by their first health consultation for MSD in 2013-2015. Latent class analysis (LCA) with count data of first year consultations for General Practitioners (GPs), hospital consultants, physiotherapists and chiropractors are used to identify combinations of health care use. Long-term high-cost patients are defined as total cost year 1-5 above 95th percentile (≥ 3 744€). RESULTS: We identified seven latent classes: 1: GP, low use; 2: GP, high use; 3: GP and hospital; 4: GP and physiotherapy, low use; 5: GP, hospital and physiotherapy, high use; 6: Chiropractor, low use; 7: GP and chiropractor, high use. Median first year health care contacts varied between classes from 1-30 and costs from 20€-838€. Eighty-seven percent belonged to class 1, 4 or 6, characterised by few consultations and treatment in primary care. Classes with high first year use were characterised by higher age, lower education and more comorbidities and were overrepresented among the long-term high-cost users. CONCLUSION: There was a large variation in first year health care service use, and we identified seven latent classes based on frequency of consultations. A small proportion of patients accounted for a high proportion of total resource use. This can indicate the potential for more efficient resource use. However, the effect of demographic and socioeconomic variables for determining combinations of service use can be interpreted as the health care system transforming unobserved patient needs into variations in use. These findings contribute to the understanding of clinical pathways and can help in the planning of future care, reduction in disparities and improvement in health outcomes for patients with MSDs.

Modelling Nonlinearities and Reference Dependence in General Practitioners' Income Preferences.

This paper tests for the existence of nonlinearity and reference dependence in income preferences for general practitioners. Confirming the theory of reference dependent utility within the context of a discrete choice experiment, we find that losses loom larger than gains in income for Norwegian general practitioners, i.e. they value losses from their current income level around three times higher than the equivalent gains. Our results are validated by comparison with equivalent contingent valuation values for marginal willingness to pay and marginal willingness to accept compensation for changes in job characteristics. Physicians' income preferences determine the effectiveness of 'pay for performance' and other incentive schemes. Our results may explain the relative ineffectiveness of financial incentive schemes that rely on increasing physicians' incomes. Copyright © 2015 John Wiley & Sons, Ltd.

General practitioners' altered preferences for private practice vs. salaried positions: a consequence of proposed policy regulations?

BACKGROUND: General practitioners (GPs) in most high-income countries have a history of being independent private providers with much autonomy. While GPs remain private providers, their autonomous position appears to be challenged by increased policy regulations. This paper examines the extent to which GPs' preferences for private practice vs. salaried contracts changed in a period where a new health care reform, involving proposed increased regulations of the GPs, was introduced. METHODS: We use data collected from Norwegian GPs through structured online questionnaires in December 2009 and May 2012. RESULTS: We find that the proportion of GPs who prefer private practice (i.e. the default contract for GPs in Norway) decreases from 52% to 36% in the period from 2009 to 2012. While 67% of the GPs who worked in private practice preferred this type of contract in 2009, the proportion had dropped by 20 percentage points in 2012. Salaried contracts are preferred by GPs who are young, work in a small municipality, have more patients listed than they prefer, work more hours per week than they prefer, have relatively low income or few patients listed. CONCLUSION: We find that GPs' preferences for private practice vs. salaried positions have changed substantially in the last few years, with a significant shift towards salaried contracts. With the proportions of GPs remaining fairly similar across private practice and salaried positions, there is an increasing discrepancy between GPs' current contract and their preferred one.

The impact of pecuniary and non-pecuniary incentives for attracting young doctors to rural general practice.

Shortages of GPs in rural areas constitute a profound health policy issue worldwide. The evidence for the effectiveness of various incentives schemes, which can be specifically implemented to boost recruitment to rural general practice, is generally considered to be poor. This paper investigates young doctors' preferences for key job attributes in general practice (GP), particularly concerning location and income, using a discrete choice experiment (DCE). The subjects were all final year medical students and interns in Norway (N = 1562), of which 831 (53%) agreed to participate in the DCE. Data was collected in November-December 2010. Policy simulations were conducted to assess the potential impact of various initiatives that can be used to attract young doctors to rural areas. Most interestingly, the simulations highlight the need to consider joint policy programs containing several incentives if the policies are to have a sufficient impact on the motivation and likelihood to work in rural areas. Furthermore, we find that increased income seem to have less impact as compared to improvements in the non-pecuniary attributes. Our results should be of interest to policy makers in countries with publicly financed GP systems that may struggle with the recruitment of GPs in rural areas.