Exploring the foundations of a digital health information service for patients with inflammatory bowel disease: a mixed method study in Gravitate-Health.

BACKGROUND: Providing relevant digital health information of high quality may promote treatment adherence and self-management for patients with inflammatory bowel disease. The development of digital health services is optimised by considering end users' needs. AIM: To identify key aspects required for digital promotion of inflammatory bowel disease patients' self-management by exploring their health information needs and the preferences of both patients and healthcare professionals in relation to the digital provision of inflammatory bowel disease health services. METHODS: Data from an audit of 1,481 electronic health record summaries from an inflammatory bowel disease help line, 17 semi-structured interviews with inflammatory bowel disease patients and 2 focus group interviews with 11 healthcare professionals were analysed. RESULTS: Patients primarily contacted the hospital due to concerns about symptoms, examinations and tests, and medicines. Their concerns appeared to vary according to diagnosis, gender, age and disease duration. The interviews identified two overarching themes: (1) the available health information and patients' health information needs, and (2) whishes, thoughts and preferences for a digital solution in IBD care with relevant and individualised information. CONCLUSIONS: The findings delineate key aspects for developing a suitable digital health information service. Patients seek information from healthcare professionals about treatment; however, in a digital solution, they want access to relevant and practical information about the disease, treatment and self-management. Both patients and healthcare professionals saw opportunities for increasing health data availability to patients. However, healthcare professionals expressed concerns about adapting, maintaining and ensuring the relevance of patient health information without increasing their workload and, thus, reducing quality of care.

Local management of the COVID-19 pandemic in Norway: a longitudinal interview study of municipality chief medical officers.

OBJECTIVE: To explore the experiences and views of Norwegian Municipality Chief Medical Officers (MCMOs) on preparedness, collaboration, and organization during the COVID-19 pandemic to gain insight into local crisis management of value for future pandemic responses. DESIGN: Longitudinal qualitative interview study. We conducted semi-structured digital interviews with nine MCMOs working in different municipalities in Norway from September to December 2020. Five MCMOs were re-interviewed from January to April 2021. We used thematic analysis to analyze the data. RESULTS: Through the analysis, three major themes were identified in the material; 1) The view of preparedness changed from being low-priority and dormant to the desire to strengthen preparedness as a permanent measure; 2) The nature of the pandemic forced a change in internal and external communication and collaboration for the MCMOs towards direct dialogue, teamwork and digital networking; 3) The pandemic changed the role and position of the MCMO within the municipal organization. Although most MCMOs were given a leading role in the municipal pandemic response, some MCMOs experienced that they were not positioned to fully exercise their intended role. In our material, de-authorization of the MCMO role seemed to coincide with the increasing size and organizational complexity of the municipality. CONCLUSIONS: The Norwegian pandemic response and outcome have been regarded as successful internationally. Although the MCMOs managed to implement flexible and quick responses facilitated by teamwork, dialogue, and joint sensemaking, they also identified several challenges and shortcomings of the Norwegian pandemic preparedness requiring organizational and financial changes to sustain future health system resilience.

The Norwegian Infection Control Act gave comprehensive responsibility and authority for local COVID-19 pandemic management to the municipalities and the Municipality Chief Medical Officers (MCMOs).The MCMOs highlighted several challenges and shortcomings of the municipal crisis preparedness, of which lack of detailed organizational plans was the most prominent.Teamwork, digital networking and collective sensemaking seemed to enhance pandemic collaboration and resilience within and across municipalities.Most MCMOs gained a leading role at a higher organizational level within the municipality through the COVID-19 pandemic.To strengthen future crisis management, arrangements must be made, both organizationally and financially, for preparedness to remain on the agenda even between epidemics and pandemics.

Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study.

OBJECTIVE: When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change. DESIGN: Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September-December 2020, the second round from January-April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2-4 months apart. To analyze the data, we used thematic analysis. RESULTS: The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal. CONCLUSIONS: Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response.Key PointsFacing the COVID-19 pandemic, the primary health care service in Norway had to reorganize to ensure safe patient treatment and maintain infection control.Several GPs experienced challenges in collaboration with the municipalities.There is a need for clarification of responsibilities between GPs and the municipality.

A preliminary simulation-based qualitative study of healthcare students' experiences of interprofessional primary care scenarios.

BACKGROUND: Introducing interprofessional education (IPE) in healthcare curricula can prepare students for healthcare practices that have become increasingly complex. The use of simulation is promoted to support IPE. This study explores healthcare students' experiences of participating in common, sub-acute patient scenarios that routinely occur in clinical practice in primary care. More specifically, it looks at how sub-acute patient scenarios from primary care can help develop interprofessional collaborative competence. METHODS: Medical students (N = 10), master's students in advanced geriatric nursing (N = 8) and bachelor's students in nursing (N = 9) participated in the simulations. The students were in their last or second-to-last year of education. We conducted five semi-structured focus group interviews with the participants' directly after the simulation training to elicit experiences related to the scenarios, the simulation and interprofessional collaboration. The transcripts were analysed using systematic text condensation. To supplement the focus group interviews, the students also completed the interprofessional collaborative competency attainment survey (ICCAS), which measures the students' self-assessed interprofessional competence. RESULTS: Three main themes emerged from the analysis of the focus group interviews: realism, uncertainty and reflection. The students emphasised the importance of authentic and recognisable scenarios. They said the vague and unspecific patient symptoms created uncertainty in the situation, making it difficult to understand the patient's diagnosis. Despite that uncertainty, they described the experience as positive. Further, the students expressed that the simulation increased their confidence in interprofessional collaboration and prepared them for future work. The results from the ICCAS questionnaire showed that the students reported a subjective positive change in their interprofessional competence after participating in the scenarios. CONCLUSIONS: This study showed that simulation-based IPE with sub-acute primary care scenarios contributes to develop interprofessional collaborative competence in healthcare education. Sub-acute scenarios can supplement the more common approaches with acute care scenarios and aid in developing the collaborative competence required to work in healthcare teams.

Exploring healthcare students' interprofessional teamwork in primary care simulation scenarios: collaboration to create a shared treatment plan.

BACKGROUND: Primary care providers assume responsibility for patients with increasingly complex problems requiring interprofessional collaboration. Introducing interprofessional education in healthcare curricula prepares healthcare students for this reality. Solving simulation scenarios as an educational strategy is promoted to support interprofessional education in health care, and is mostly used in acute clinical situations. This paper aims to explore how healthcare students' actions influence interprofessional collaboration and treatment plan identification when they solve common, sub-acute patient scenarios in primary care situations. METHODS: Interaction analysis of video recordings from the simulation scenarios was performed with a focus on the students' joint actions; specifically how these actions unfold and how productive the students were in terms of developing treatment plans. RESULTS: We found variation in the groups' interactions, the paths they followed, and the quality of their knowledge output in their shared treatment plan. The groups with the capacity to collaborate and engage in sharing information, and explain and elaborate on concepts, were more successful in developing comprehensive treatment plans. Furthermore, these groups managed the duality of defining and solving the immediate problem and collaboratively preparing for future care. CONCLUSIONS: Analysis of the activities in our scenarios showed the students' potential to practice interprofessional collaboration. Our study illustrates that simulation of sub-acute scenarios in primary care is an underexplored but suitable arena to train communication and teamwork in complex situations. The simulation scenarios are also feasible for use on-site in an educational facility or in practice with minimal equipment and resources.

Evidence of validity for the Norwegian version of the interprofessional collaborative competency attainment survey (ICCAS).

This was a validation study of the Norwegian version of The Interprofessional Collaborative Competency Attainment Survey (ICCAS). ICCAS consists of 20 retrospective pre- and post-questions, where respondents rate their agreement with regard to self-assessed competencies after participating in interprofessional education courses. It has been validated across various settings. The questionnaire was translated using the back-translation technique. We investigated evidence of validity regarding content, response process, and internal structure. Data were obtained from health and social care students (n = 1440, response rate 42.8%) participating in 12 different interprofessional courses in seven education institutions in Norway using a cross-sectional design. Exploratory factor analysis indicated one retracted factor for pre-scores and one retracted factor for post-scores. High McDonald's omega values indicated good internal consistency. Item deletion did not improve the scale's overall consistency on pre- or post-scores. We observed higher mean post-scores than pre-scores with moderate-to-large effect sizes, indicating a positive change in self-assessed interprofessional capabilities after training. Our findings indicate that the Norwegian version of ICCAS is a valid tool that may be implemented across a wide range of interprofessional education courses. Finally, our findings support earlier recommendations that ICCAS should be analyzed at an overall level to address change in interprofessional capabilities.

Learning Clinical Assessment and Interdisciplinary Team Collaboration in Primary Care. MOOC for Healthcare Practitioners and Students.

Novel ways to build sufficient capacity to meet the need for competent healthcare providers in primary care are in strong demand. We developed a massive, open, online course (MOOC) to introduce and promote clinical skills development for healthcare workers (physicians, nurse practitioners, nurses, and nurse aids) and students in healthcare education (medical students and master and bachelor students in nursing) focusing on systematic health assessment and strengthening clinical decision making in primary care. Results from the pilot supports that the MOOC was relevant and highly useful for the participants, and has potential to contribute to interdisciplinary collaboration and discussions.

CarerSupport - An Innovative Approach to Informal Carers' Training and Collaboration.

EU and national policies for long-term care acknowledge the role of informal carers. However, there is still little adequate support to prepare or ease informal carers in terms of training to allow them improve their skills, alleviate psychosocial stress and maintain their own health and well-being. In the CarerSupport project, we seek to integrate services, deploy and test an integrated ICT platform enabling participation and collaboration of informal carers, psychologists and health professionals to collaborate, facilitate training and orientation, offer tele-consulting services and psychosocial support to carers. Based on this platform and its content, we will deploy and report on informal carers' experiences with the wide range of offered service. The poster will present the first experiences and suggest potentials for a service like CarerSupport.

Costs analysis and comparison of usefulness of acute MRI and 2 weeks of cast immobilization for clinically suspected scaphoid fractures.

BACKGROUND AND PURPOSE: Fractures of the scaphoid are often not detected on initial plain radiographs. Conventional management of clinically suspected scaphoid fractures is cast immobilization for 2 weeks and then reassessment. Early MRI is a diagnostic alternative. We compared the cost and usefulness of the early MRI diagnostic strategy with that of conventional management. PATIENTS AND METHODS: This prospective pseudo-randomized study included patients between 18 and 49 years of age who attended Bergen Accident and Emergency Department, Bergen, Norway during 1 year in 2009-2010, after sustaining an acute wrist trauma in the previous week and with a clinically suspected scaphoid fracture. 61 patients were investigated with acute MRI, while 63 patients received standard treatment as a control group. We used cost-minimization analysis to estimate the cost of the 2 patient groups. RESULTS: Concerning cost, there were no statistically significant differences in the total direct medical costs or in indirect costs between the groups. Concerning usefulness, patients in the MRI group without a fracture (n = 35) used a cast for fewer days (mean 1 day) than patients in the control group with no fractures (n = 52) (mean 14 days; p < 0.001). They had less than half the number of days on sick leave than patients in the control group (mean 7 days vs. 15 days; p = 0.002). INTERPRETATION: In a Norwegian setting, an early MRI was of value in patients with clinically suspected scaphoid fracture and normal plain radiographs.

Can EQ-5D and 15D be used interchangeably in economic evaluations? Assessing quality of life in post-stroke patients.

This paper provides an analysis on the use of 15D and EQ-5D to measure health related quality of life. Measures like these are often used interchangeably in cost-effectiveness studies. However, it is unclear whether they measure the same level of health in the same patients. The empirical performance of the two multi-attribute utility instruments is tested in terms of feasibility, utility score, linear relationship and agreement by using a novel Norwegian data set. The paper also includes an analysis of how the instruments rank individuals in terms of health status, and their discriminatory power are tested. The results show that EQ-5D and 15D should not be used interchangeably in economic evaluations. EQ-5D is likely to give a more favourable cost utility ratio than 15D. The utility scores generated from the two instruments differ significantly different from each other, even though they correlate well. The instruments also rank individuals in terms of health status differently.

The effects of fatigue, pain, and depression on quality of life in ischemic stroke patients: the Bergen Stroke Study.

BACKGROUND: Many patients with cerebral infarction suffer from symptoms such as pain, fatigue, and depression. The aim of this study was to evaluate these symptoms in relation to health-related quality of life (HRQoL) on long-term follow-up. MATERIALS AND METHODS: All surviving stroke patients admitted to the Stroke Unit, Haukeland University Hospital, Norway between February 2006 and November 2008 were sent a questionnaire, including a visual analog pain scale, Fatigue Severity Scale, Depression Subscale of Hospital Anxiety and Depression Scale, Barthel Index, and three measures of HRQoL--15D, EuroQol, and EuroQol Visual Analogue Scale--at least 6 months after stroke onset. Cox regression survival analysis, including EQ-5D, was performed by November 2009. RESULTS: The questionnaire was returned by 328 patients. All three symptoms were reported by 10.1% of the patients, and 26% reported two symptoms. There was a significant association between worse HRQoL scores and an increasing number of cooccurring symptoms for all three HRQoL scores. Fatigue, depression, pain, functional state, and sleeping disorder on follow-up accounted for 58%-83% of the variability in HRQoL, depending on which HRQoL scale was used. Cox regression analysis showed that mortality was associated with a low EuroQol score (P = 0.016). CONCLUSION: Pain, fatigue, and depression were common symptoms among these stroke patients and, to a large extent, they determined the patients' HRQoL. Low HRQoL was associated with increased mortality.

The triad of pain, fatigue and depression in ischemic stroke patients: the Bergen Stroke Study.

BACKGROUND: Many patients with cerebral infarction suffer from symptoms such as pain, fatigue and depression. Most studies focus on single symptoms, but these symptoms often occur together. Whereas symptom clusters have been studied in cancer patients, little is known about different symptom clusters in patients with cerebral infarction. The aim was to evaluate clusters of co-occurring symptoms in the long term. We hypothesized that patients with cerebral infarction display distinct symptom clusters. Furthermore, we hypothesized that multiple co-occurring symptoms have an adverse effect on patients. METHODS: All consecutive patients with acute stroke (the index stroke) admitted to the Stroke Unit, Department of Neurology, Haukeland University Hospital, between February 2006 and July 2008, were prospectively registered in a database. Prior risk factors (including diabetes mellitus, hypertension, smoking, coronary heart disease, atrial fibrillation and prior stroke), prior depression and stroke severity (modified Rankin Scale (mRS) score on day 7) were registered. Patients with cerebral infarction were sent a questionnaire including a visual analogue pain scale (VAS), Fatigue Severity Scale (FSS), depression subscale of the Hospital Anxiety, Depression Scale (HADS-D) and Barthel Index at least 6 months after stroke onset. RESULTS: The questionnaire was returned by 328 patients (response rate 60%). All three symptoms were reported by 10.1%. Pain and fatigue among nondepressed patients were reported by 19.6%. Pain and depression among nonfatigued patients were reported by 2.0%. Depression and fatigue, and no pain were reported by 4.4%. Single symptoms were reported by 31% whereas 33% reported no symptoms. VAS, FSS and HADS-D score severity increased with the number of co-occurring symptoms. Logistic regression analyses showed that two or three symptoms (versus no symptoms) was associated with high mRS score on day 7 (p = 0.02), prior stroke (p = 0.002), prior diabetes mellitus (p = 0.005) and prior depression (p < 0.001). CONCLUSIONS: Symptom clusters are frequent in patients with cerebral infarction. Fatigue was associated with pain and depression whereas there was little association between depression and pain in nonfatigue patients, indicating distinct symptom clusters. The severity of symptoms increased with the number of co-occurring symptoms.

Fatigue among stroke patients on long-term follow-up. The Bergen Stroke Study.

BACKGROUND: To evaluate characteristics and mortality related to post-stroke fatigue (PSF). METHODS: All surviving stroke patients admitted to the Stroke Unit, Haukeland University Hospital, between February 2006 and November 2008 were sent a postal questionnaire including the Fatigue Severity Scale (FSS), the hospital anxiety and depression scale (HADSD), and the Barthel Index (BI) at least 6 months after stroke onset. Survival among patients returning the questionnaire was determined by November 2009. PSF was defined as FSS score ≥5. RESULTS: Among 377 patients returning the questionnaire, 42.3% had PSF. Logistic regression showed that PSF was independently associated with pre-stroke depression, leucoaraiosis, myocardial infarction, diabetes mellitus, pain, and sleeping disturbances. Mean FSS score was lower among TIA patients than among patients with minor cerebral infarction (patients with BI=100) (P=.002). Cox regression analysis showed mortality to be associated with PSF. CONCLUSION: There is a multifactorial basis for PSF suggesting different therapy options. Cerebral lesions may cause PSF in some patients. Post-stroke fatigue is associated with higher mortality.

Post-stroke pain on long-term follow-up: the Bergen stroke study.

The objective of this study is to evaluate characteristics and mortality related to long-term post-stroke pain (PSP). All surviving stroke patients admitted to the Stroke Unit, Haukeland University Hospital, between February 2006 and July 2009 received a postal questionnaire including the fatigue severity scale (FSS), the hospital anxiety and depression scale (HADSD), the Barthel index (BI), and questions regarding location of pain and pain severity at least 6 months after onset of stroke. Survival among patients returning the questionnaire was determined by November 2009. Stroke severity was defined by the modified Rankin score (mRS), 7 days after stroke onset. About 30% of the 408 patients had moderate to severe PSP. On logistic regression, PSP was associated with females (odds ratio (OR) = 2.1, p = 0.002), lower age (OR = 0.98, p = 0.04), fatigue (OR = 3.1, p < 0.001), sleep disturbances (OR = 3.3, p < 0.001), and mRS 3-5 (OR = 1.9, p = 0.03). Among patients with pareses (persistent or transient), there was no difference between paretic and non-paretic side as to frequency of limb pain on follow-up (p = 0.91). By November 2009, 26 patients had died. Cox regression analysis showed that mortality was associated with PSP (hazard ratio (HR) = 2.4, p = 0.040), high age (HR = 1.07, p = 0.001), males (HR = 2.5, p = 0.04), and low BI (HR = 0.97, p < 0.001). In conclusion, our study indicates a multifactorial basis for post-stroke pain. The main new findings were that the frequencies of pain were similar in paretic and non-paretic limbs and that long-term mortality was associated with post-stroke pain.