Does assistive technology contribute to safety among home-dwelling older adults?

BACKGROUND: Assistive technology carries the promise of alleviating public expenditure on long-term care, while at the same time enabling older adults to live more safely at home for as long as possible. Home-dwelling older people receiving reablement and dementia care at their homes are two important target groups for assistive technology. However, the need for help, the type of help and the progression of their needs differ. These two groups are seldom compared even though they are two large groups of service users in Norway and their care needs constitute considerable costs to Norwegian municipalities. The study explores how assistive technology impacts the feeling of safety among these two groups and their family caregivers. METHODS: Face-to-face, semi-structured interviews lasting between 17 and 61 min were conducted between November 2018 and August 2019 with home-dwelling older adults receiving reablement (N = 15) and dementia care (N = 10) and the family caregivers (N = 9) of these users in seven municipalities in Norway. All interviews were audio-recorded, fully transcribed, thematically coded and inductively analyzed following Clarke and Braun's principles for thematic analysis. RESULTS: Service users in both groups felt safe when knowing how to use assistive technology. However, the knowledge of how to use assistive technology was not enough to create a feeling of safety. In fact, for some users, this knowledge was a source of anxiety or frustration, especially when the user had experienced the limitations of the technology. For the service users with dementia, assistive technology was experienced as disturbing when they were unable to understand how to handle it, but at the same time, it also enabled some of them to continue living at home. For reablement users, overreliance on technology could undermine the progress of their functional improvement and thus their independence. CONCLUSION: For users in both service groups, assistive technology may promote a sense of safety but has also disadvantages. However, technology alone does not seem to create a sense of safety. Rather, it is the appropriate use of assistive technology within the context of interactions between service users, their family caregivers and the healthcare staff that contributes to the feeling of safety.

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.

The Causal Effect of Community Hospitals on General Hospital Admissions. Evaluation of a Natural Experiment Using Register Data.

Background: To reduce overall healthcare costs, several countries have attempted to shift services from specialist to primary care. This was also the main strategy of the Coordination Reform introduced in Norway in 2012. An important part of the reform was the introduction of Municipal Acute Wards (MAWs), a type of community hospital aimed at reducing admissions to general hospitals. The main objective of this paper is to investigate whether the implementation of MAWs had a causal effect on hospital admissions. Methods: Monthly admission rates in total and by age groups for patients admitted with acute or elective conditions at internal medicine or surgical departments were analyzed using panel data regression techniques. We identified causal effects by exploiting the sequential roll out of the MAWs within fixed effect analyses. Our data covered all municipalities from start of 2010 until the end of 2017. Results: The sequential implementation of the MAWs started during the summer of 2012. By the beginning of 2016 close to all municipalities had an operative MAW. The introduction of MAWs significantly reduced acute hospital admissions. The effect was strongest for patients ≥80 years admitted acutely to internal medicine departments. The effects were even stronger if the MAW had a physician on site 24/7 or was located close to a local emergency center. Conclusion: Our findings suggest that this type of intermediate care unit is a viable option to alleviate the burden on hospitals by reducing acute secondary care admission volumes.

A qualitative study on promoting reablement among older people living at home in Norway: opportunities and constraints.

BACKGROUND: Healthcare services that traditionally have been provided in long-term care institutions in Norway are increasingly being delivered at home to a growing population of older people with chronic conditions and functional limitations. Fostering reablement among older people is therefore important if they are to live safety at home for as long as possible. This study examines how healthcare professionals and managers (staff) in Norwegian municipalities promote reablement among community-dwelling older people. METHODS: Face-to-face, semi-structured interviews lasting between 21 and 89 min were conducted between November 2018 and March 2019 with healthcare managers (N = 8) and professionals (N = 8 focus groups with 2-5 participants) in six municipalities in Norway. All interviews were audio-recorded, transcribed, and thematically coded inductively and analyzed with the aid of NVivo 12 software. RESULTS: Overall, healthcare staff in this study used several strategies to promote reablement, including: carrying out assessments to evaluate older people's functional status and needs (including for safe home environments), and to identify older people's wishes and priorities with regard to reablement training. Staff designed care plans informed by the needs assessments, and worked with older people on reablement training at a suitable pace. They promoted among older people and staff (within and across care-units) the principle of 'showing/doing with' versus 'doing for' the older person so as to not enable disablement. Additionally, they supported older people in the safe and responsible use of welfare technology and equipment. Even so, staff also reported constraints to their efforts to foster reablement, such as: heavy workload, high turnover, insufficient training in reablement care, and poor collaboration across care-units. CONCLUSION: Older people may be supported to live safely at home by meeting them as individuals with agency, identifying and tailoring services to their needs and wishes, and encouraging their functional abilities by 'showing/doing with' versus 'doing for them' when possible. The healthcare professionals and managers in this study were positive towards reablement care. However, meeting the resource demands of reablement care is a key challenge.

Does rehabilitation setting influence risk of institutionalization? A register-based study of hip fracture patients in Oslo, Norway.

BACKGROUND: Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients' subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6-12 months from the index admission). METHODS: Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients' age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo's boroughs to control for supply-side and unobserved effects. RESULTS: The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23-0.76) of living in a nursing home at 6-12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF. CONCLUSIONS: The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

Work-related moderators of the relationship between organizational change and sickness absence: a longitudinal multilevel study.

BACKGROUND: A sizeable body of research has demonstrated a relationship between organizational change and increased sickness absence. However, fewer studies have investigated what factors might mitigate this relationship. The aim of this study was to examine if and how the relationship between unit-level downsizing and sickness absence is moderated by three salient work factors: temporary contracts at the individual-level, and control and organizational commitment at the work-unit level. METHODS: We investigated the association between unit-level downsizing, each moderator and both short- and long-term sickness absence in a large Norwegian hospital (n = 21,085) from 2011 to 2016. Data pertaining to unit-level downsizing and employee sickness absence were retrieved from objective hospital registers, and moderator variables were drawn from hospital registers (temporary contracts) and the annual work environment survey (control and organizational commitment). We conducted a longitudinal multilevel random effects regression analysis to estimate the odds of entering short- (< = 8 days) and long-term (> = 9 days) sickness absence for each individual employee. RESULTS: The results showed a decreased risk of short-term sickness absence in the quarter before and an increased risk of short-term sickness absence in the quarter after unit-level downsizing. Temporary contracts and organizational commitment significantly moderated the relationship between unit-level downsizing in the next quarter and short-term sickness absence, demonstrating a steeper decline in short-term sickness absence for employees on temporary contracts and employees in high-commitment units. Additionally, control and organizational commitment moderated the relationship between unit-level downsizing and long-term sickness absence. Whereas employees in high-control work-units had a greater increase in long-term sickness absence in the change quarter, employees in low-commitment work-units had a higher risk of long-term sickness absence in the quarter after unit-level downsizing. CONCLUSIONS: The results from this study suggest that the relationship between unit-level downsizing and sickness absence varies according to the stage of change, and that work-related factors moderate this relationship, albeit in different directions. The identification of specific work-factors that moderate the adverse effects of change represents a hands-on foundation for managers and policy-makers to pursue healthy organizational change.

Organizational change and the risk of sickness absence: a longitudinal multilevel analysis of organizational unit-level change in hospitals.

BACKGROUND: Organizational change is often associated with reduced employee health and increased sickness absence. However, most studies in the field accentuate major organizational change and often do not distinguish between and compare types of change. The aim of this study was to examine the different relationships between six unit-level changes (upsizing, downsizing, merger, spin-off, outsourcing and insourcing) and sickness absence among hospital employees. METHODS: The study population included employees working in a large Norwegian hospital (n = 26,252). Data on unit-level changes and employee sickness absence were retrieved from objective hospital registers for the period January 2011 to December 2016. The odds of entering short- (< = 8 days) and long-term (> = 9 days) sickness absence for each individual employee were estimated in a longitudinal multilevel random effects logistic regression model. RESULTS: Unit-level organizational change was associated with both increasing and decreasing odds of short-term sickness absence compared to stability, but the direction depended on the type and stages of change. The odds of long-term sickness absence significantly decreased in relation to unit-level upsizing and unit-level outsourcing. CONCLUSIONS: The results from this study suggested that certain types of change, such as unit-level downsizing, may produce greater strain and concerns among employees, possibly contributing to an increased risk of sickness absence at certain stages of the change. By contrast, changes such as unit-level insourcing and unit-level upsizing were related to decreased odds of sickness absence, possibly due to positive change characteristics.

The health policy pendulum: Cost control vs activity growth.

BACKGROUND: Cost containment is a major policy challenge and one of the key drivers of health care reform. In this article, we focus on the role cost control has played as a reform driver in the Norwegian hospital sector between 1980 and 2014. METHODS: We use data on aggregate expenditure as well as on activity changes from year to year. We also use qualitative data for illustrative purposes. RESULTS: We identify 4 phases in the period 1980 to 2014: two where activity increases have dominated the agenda and 2 where cost control has been emphasized. The desire to either increase activity or improve cost control has been important reform drivers. CONCLUSION: Cost control has been a major reform motivator in the period, and some of the policies aimed towards achieving cost control have been successful. But as cost control is achieved, waiting lists and popular dissatisfaction increase and new policies are implemented to increase activity.

General practitioners' perspectives on care coordination in primary health care: A qualitative study.

INTRODUCTION: To explore Norwegian general practitioners' experiences with care coordination in primary health care. METHODS: Qualitative study using data from five focus groups with 32 general practitioners in Norway. We analysed the data using systematic text condensation, a descriptive and explorative method for thematic cross-case analysis of qualitative data. RESULTS: The general practitioners had different notions of care pathways. They expressed a wish and an obligation to be involved in planning and coordination of primary health-care services, but they experienced organisational and financial barriers that limited their involvement and contribution. General practitioners reported lack of information about and few opportunities for involvement in formal coordination initiatives, and they missed informal arenas for dialogue with other primary health-care professionals. They argued that the general practitioner's role as coordinator should be recognised by other parties and that they needed financial compensation for contributions and attendance in meetings with the municipality. DISCUSSION: General practitioners need informal arenas for dialogue with other primary health-care professionals and access to relevant information to promote coordinated care. There might be an untapped potential for improving patient care involving general practitioners more in planning and coordinating services at the system level. Financial compensation of general practitioners contribution may promote increased involvement by general practitioners.

The effects of the Norwegian Coordination Reform on the use of rehabilitation services: panel data analyses of service use, 2010 to 2013.

BACKGROUND: In 2012 the Norwegian Coordination Reform was implemented. The main motivation was to encourage municipalities to expand local, primary health care services. From 2012 to 2014, under the Municipal Co-Financing regime, municipalities were obliged to cover 20 % of the costs of health services provided at the specialist (hospital) level. Importantly, use of rehabilitation services in private institutions was not part of the cost-sharing mechanism of Municipal Co-Financing. Rehabilitation services may be seen as quite similar in nature whether they be provided by municipalities, hospitals or private institutions. Thus, with rehabilitation patients readily "transferrable" between levels, the question is whether the reform brought with it a sought after shift towards more municipal rehabilitation and less specialist rehabilitation. METHODS: Data from the Norwegian Patient Register and from Statistics Norway/KOSTRA were utilized to gauge annual expenditures and inputs in specialist, municipal and private institution rehabilitation services respectively. Fixed effects and first difference regression analyses for the period 2010-2013 were carried out to account for certain time-invariant traits of municipalities and/or hospital regions, and results were adjusted for contemporaneous trends in local needs. RESULTS: Expenditures in specialist rehabilitation services declined sharply (typically by 8-10 %) from 2011 (pre-reform) to 2012 (post-reform), while expenditures in private rehabilitation services rose markedly in the same period (typically by 42-44 %). The results do not suggest any general expansion of municipal rehabilitation services. CONCLUSIONS: The results of the analyses suggest that municipalities shift away from the use of specialist rehabilitation services and towards the use of rehabilitation services in private institutions since the latter becomes relatively cheaper (free-of charge) than both municipal and specialist services in post-reform periods (as specialist services come at a cost to municipalities post-reform). While the main goal of the reform has not materialized the results nevertheless suggest that incentives (of cost-shifting) do play a significant role in rehabilitation service use.

The role of young users in determining long-term care expenditure in Norway.

AIMS: In Norway, it is the responsibility of the country's 429 municipalities to provide long term care (LTC) services to their residents. Recent years have seen a sharp rise in the number of LTC users under the age of 65. This article aims to explore the effect of this rise on LTC expenditure. METHODS: Panel data models are used on data from municipalities from 1986 to 2011. An instrumental variable approach is also utilized to account for possible endogeneity related to the number of young users. RESULTS: The number of young users appears to have a strong effect on LTC expenditure. There is also evidence of municipalities exercising discretion in defining eligibility criteria for young users in order to limit expenditure. CONCLUSIONS: The rise in the number of young LTC users presents a long-term challenge to the sustainability of LTC financing. The current budgeting system appears to compensate municipalities for expenditure on young LTC users.

Elderly demand for family-based care and support: evidence from a social intervention strategy.

This paper examines the influence of the national health insurance scheme on elderly demand for family-based care and support. It contributes to the growing concern on the rapid increase in the elderly population globally using micro-level social theory to examine the influence the health insurance has on elderly demand for family support. A qualitative case study approach is applied to construct a comprehensive and thick description of how the national health insurance scheme influences the elderly in their demand for family support.Through focused interviews and direct observation of six selected cases, in-depth information on primary carers, living arrangement and the interaction between the health insurance as structure and elders as agents are analyzed. The study highlights that the interaction between the elderly and the national health insurance scheme has produced a new stratum of relationship between the elderly and their primary carers. Consequently, this has created equilibrium between the elderly demand for support and support made available by their primary carers. As the demand of the elderly for support is declining, supply of support by family members for the elderly is also on the decline.

Does competition among general practitioners increase or decrease the consumption of specialist health care?

Studies of the effects of capacity and competition among general practitioners (GPs) on the use of specialist health care services are inconclusive. Some studies indicate that an increase in the number of GPs leads to increased consumption of specialist health care, while other studies point in the opposite direction. This article adds to the literature in two ways; first by testing out different operationalization of capacity and competition among GPs, and then by testing out effects of capacity and competition on use of specialist health care services as this is disaggregated into ambulatory and inpatient activities. The empirical tests indicate that GP capacity in itself does not affect use of specialist health care services. Increased competitions among GPs do, however, reduce the use of ambulatory care while the effects on the use of inpatient services are unaffected.

The politics of local hospital reform: a case study of hospital reorganization following the 2002 Norwegian hospital reform.

BACKGROUND: The Norwegian hospital reform of 2002 was an attempt to make restructuring of hospitals easier by removing politicians from the decision-making processes. To facilitate changes seen as necessary but politically difficult, the central state took over ownership of the hospitals and stripped the county politicians of what had been their main responsibility for decades. This meant that decisions regarding hospital structure and organization were now being taken by professional administrators and not by politically elected representatives. The question raised here is whether this has had any effect on the speed of restructuring of the hospital sector. METHOD: The empirical part is a case study of the restructuring process in Innlandet Hospital Trust (IHT), which was one of the largest enterprise established after the hospital reform and where the vision for restructuring was clearly set. Different sources of qualitative data are used in the analysis. These include interviews with key actors, observational data and document studies. RESULTS: The analysis demonstrates how the new professional leaders at first acted in accordance with the intentions of the hospital reform, but soon chose to avoid the more ambitious plans for restructuring the hospital structure and in fact reintroduced local politics into the decision-making process. The analysis further illustrates how local networks and engagement of political representatives from all levels of government complicated the decision-making process surrounding local structural reforms. Local political representatives teamed up with other actors and created powerful networks. At the same time, national politicians had incentives to involve themselves in the processes as supporters of the status quo. CONCLUSION: Because of the incentives that faced political actors and the controversial nature of major hospital reforms, the removal of local politicians and the centralization of ownership did not necessarily facilitate reforms in the hospital structure. Keeping politics at an arm's length may simply be unrealistic and further complicate the politics of local hospital reforms.

[Hospital discharge information as a communication tool]. / Epikrisen som samhandlingsverktøy.

BACKGROUND: The main objective of the list patient health reform has been to improve the quality of local medical service. In European healthcare systems, there has been a need for coordination between primary and secondary care. It has been claimed that the communication between GPs and specialised health care is insufficient, particularly for patients with an extended need of care. MATERIAL AND METHODS: Data on collaboration and satisfaction with specialised health services was collected in a cross-sectional questionnaire survey comprising all Norwegian GPs in 2004 (N = 633); the response rate was 48%. RESULTS: Median delay in receiving patient information was one week or more for inpatient and outpatient treatment. Overall, GPs were satisfied with the hospitals' discharge reports, except for patients needing extended follow up by GPs after discharge. In these patients, GPs more frequently needed to contact the hospital because of insufficient data or unacceptable delays. Female GPs were less satisfied with information services in patients with increased needs. There were also geographical differences in satisfaction. INTERPRETATION: In patients with an increased need for follow up, GPs are less satisfied with hospital information service.

[Use of incentives to enhance response rates in questionnaire surveys]. / Bruk av incentiver for å øke svarandelen i spørreskjemaundersøkelser.

BACKGROUND: The purpose of this article is to relate response rates in surveys among GPs to the use of conditional and non-conditional incentives. MATERIAL AND METHOD: The data were gathered during a nation-wide survey among all Norwegian general practitioners. RESULTS: There was a higher response rate among respondents who received non-conditional incentives. Although not significant at the 5 percent level, the effect is sufficiently strong to be characterised as interesting. INTERPRETATION: The results indicate that non-conditional incentives are effective in enhancing the response rate in surveys among GPs.

Coordinating health care: lessons from Norway.

OBJECTIVE: What influences the coordination of care between general practitioners and hospitals? In this paper, general practitioner satisfaction with hospital-GP interaction is revealed, and related to several background variables. METHOD: A questionnaire was sent to all general practitioners in Norway (3388), asking their opinion on the interaction and coordination of health care in their district. A second questionnaire was sent to all the somatic hospitals in Norway (59) regarding formal routines and structures. The results were analysed using ordinary least squares regression. RESULTS: General practitioners tend to be less satisfied with the coordination of care when their primary hospital is large and cost-effective with a high share of elderly patients. Together with the degree to which the general practitioner is involved in arenas where hospital physicians and general practitioners interact, these factors turned out to be good predictors of general practitioner satisfaction. IMPLICATION: To improve coordination between general practitioners and specialists, one should focus upon the structural traits within the hospitals in different regions as well as creating common arenas where the physicians can interact.