Anders Grimsmo

Patients, diagnoses and processes in general practice in the Nordic countries. An attempt to make data from computerised medical records available for comparable statistics

OBJECTIVE To try out a collection of a standard set of data from computerised medical records. DESIGN Retrospective extraction of ordinary patient record information put into the computer by general practitioners. SETTING Encounters in office hours in strategically selected practices or health centres in Denmark, Finland, Iceland, Norway and Sweden. SUBJECTS 59 general practitioners and a total study population of 97475 persons. MAIN OUTCOME MEASURES Proportions, crude and specific rates of encounters, diagnoses and processes. RESULTS In a 4-week period there was a threefold difference in the office encounter rates between the participating sites in the Nordic countries. Gender and age patterns were similar despite these differences. An access to several different denominators revealed diverse patterns of referring to the specialist, prescribing, ordering blood tests, X-rays and physiotherapy. Data from computerised medical records agree well with earlier studies in the Nordic countries using other methods. CONCLUSIONS This survey demonstrates that valid and reliable data for routine statistics are available from computerised medical records in general practice. The major obstacle extracting more epidemiological data from computerised medical records is caused by information in the databases not being uniquely linked to episodes of care.Objective - To try out a collection of a standard set of data from computerised medical records. Design - Retrospective extraction of ordinary patient record information put into the computer by general practitioners. Setting - Encounters in office hours in strategically selected practices or health centres in Denmark, Finland, Iceland, Norway and Sweden. Subjects - 59 general practitioners and a total study population of 97475 persons. Main outcome measures - Proportions, crude and specific rates of encounters, diagnoses and processes. Results - In a 4-week period there was a threefold difference in the office encounter rates between the participating sites in the Nordic countries. Gender and age patterns were similar despite these differ ences. An access to several different denominators revealed diverse patterns of referring to the specialist, prescribing, ordering blood tests, X-rays and physiotherapy. Data from computerised medical records agree well with earlier studies in the Nordic countries using other methods. Conclusions - This survey demonstrates that valid and reliable data for routine statistics are available from computerised medical records in general practice. The major obstacle extracting more epidemiological data from computerised medical records is caused by information in the databases not being uniquely linked to episodes of care.

Development of a patient-centred care pathway across healthcare providers: a qualitative study

BackgroundDifferent models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway.MethodsThis qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants.ResultsThe development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient’s functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals.ConclusionsDisease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended.

Assessment of left ventricular function by GPs using pocket-sized ultrasound

Background Assessment of left ventricular (LV) function with echocardiography is mandatory in patients with suspected heart failure (HF). Objectives To investigate if GPs were able to evaluate the LV function in patients at risk of developing or with established HF by using pocket-sized ultrasound (pUS). Methods Feasibility study in general practice, seven GPs in three different Norwegian primary care centres participated. Ninety-two patients with reduced or at risk of developing reduced LV function were examined by their own GP using pUS. The scan (<5 minute) was done as part of a routine appointment. A cardiologist examined the patients <30 minutes afterwards with both a laptop scanner and pUS. Measurements of the septal mitral annular excursion (sMAE) were compared. Results In 87% of the patients, the GPs were able to obtain a standard view and measure the sMAE. There was a non-significant mean difference in sMAE between GP pUS and cardiologist laptop scanner of −0.15 mm 95% confidence interval (−0.60 to 0.30) mm. A comparison of the pUS recordings and measurements of sMAE made by GP versus cardiologist revealed a non-significant mean difference with acceptable 95% limits of agreement (−0.26 ± 3.02 mm). Conclusions With tailored training, GPs were able to assess LV function with sMAE and pUS. pUS, as a supplement to the physical examination, may become an important tool in general practice.

Toward Increased Patient Safety? Electronic Communication of Medication Information Between Nurses in Home Health Care and General Practitioners

This study investigates how the use of an electronic messaging system influences patient safety in the medication information process between home health care nurses and general practitioners. Focus group interviews and semistructured interviews with 34 nurses and general practitioners were applied, and the results show that using a messaging system in the clinical communication and collaboration led to nurses in home health care and general practitioners more easily connecting, medication information being more accessible and medication information having a higher quality. The results also revealed that the use of a messaging system caused errors in the medication information. However, according to the nurses in home health care and general practitioners, the overall conclusion was that medication information improved and thereby patient safety increased.

Closing information gaps with shared electronic patient summaries––How much will it matter?

BACKGROUND Information deficits contribute to medical errors. Hence several efforts to develop electronic communication systems to facilitate a flow of information between health care providers have been attempted, including initiatives to develop regional or national electronic patient summaries. OBJECTIVES To study information access and information needs in inpatient emergency departments, and how clinicians in these departments handle deficits in available information. METHODS We conducted an observational study of consecutive unplanned inpatient admissions using a structured form to register a set of predefined parameters and free-text notes, including a post-examination interview with the examining emergency department doctors and nurses. RESULTS We observed 177 patient admissions, excluding any patients under 18 years of age and planned admissions. One in four patients arrived without any referral. Nearly all referrals described the presenting complaint with a tentative diagnosis. One third of the referrals lacked medication record and medical history. Only one in ten referrals contained information about contraindications. If the patient had previously been admitted to the hospital, the emergency department doctors used the existing electronic patient record and seemed to favor previous discharge letters as an information source. Information on current medications was often copied from earlier admissions. In half of the cases the patients also provided supplementary information in other ways not available, though one in five patients was not in a cognitive state to be properly interviewed. The examining doctors reported a lack of crucial information in 10% of the observed referrals. CONCLUSION Overall, information about medications and previous history was described in most referrals, but was still the information most frequently inquired or searched for. Qualitative assessments revealed that insufficient information put a significant stress on both patients and staff, and in turn caused additional workload and risky work-arounds. In our assessment, these information deficits could be effectively mitigated by an up to date easy-access patient summary.

Parent-held child health records do not improve care: A randomized controlled trial in Norway

Objective. To study the effects of a parent-held child health record (PHCHR) that was created by the Norwegian Board of Health with the purpose of introducing this to the whole country. Design. Randomized controlled trial. Setting. Maternal and child health centres in 10 municipalities in Norway. Subjects. Parents of 309 children attending the National Preschool Health Surveillance Programme. Intervention. Half of the parents were given a PHCHR and short instructions on how it was expected to be used. Main outcome measures. Parent–professional collaboration, healthcare utilization, and parents’ knowledge about child health matters and illness. Results. Some 73% of the intervention group used the PHCHR regularly when visiting the health centres, 79% reported that their own writing in the record was helpful, and 92% favoured the PHCHR being permanently adopted. Use of the record did not influence the utilization of healthcare services, parents’ knowledge of their childs health, or parents’ satisfaction with information or communication with professionals. Conclusions. The PHCHR was well accepted by parents and professionals but it had no effects on collaboration, healthcare utilization, or other measures that could justify the costs of introducing the record into common use. Therefore, the introduction of a parent-held child health record in Norway is being postponed.

Early experiences with the multidose drug dispensing system – A matter of trust?

Abstract Objective. To study early experiences with multidose drug dispensing (MDD) among different groups of health personnel. Design. Qualitative study based on focus-group interviews. Setting. Primary health care, Trondheim, Norway. Main outcome. The importance of trust in the technology and in collaborating partners is actualized in the early implementation of MDD. Results. GPs, home-care nurses, pharmacists, and medical secretaries trusted the new MDD technology. The quality of the GPs’ medication records improved. However, health personnel, including the GPs themselves, would not always trust the medication records of the GPs. Checking the multidose bags arriving from the pharmacy was considered unnecessary in the written routines dealing with MDD. However, home-care nurses experienced errors and continued to manually check the bags. Nurses in the home-care service felt a loss of knowledge with regard to the patients’ medications and in turn experienced reduced ability to give medical information to patients and to observe the effects of the drugs. The home-care services’ routines for drug handling were not always trusted by the other groups of health personnel involved. Conclusion. Health personnel faced some challenges during the implementation of the MDD system, but most of them remained confident in the new system. Building trust has to be a process that runs in parallel with the introduction of new technology and the establishment of new routines for improving the quality in handling of medicines and to facilitate better cooperation and communication.

Hospital Admissions from Nursing Homes: Rates and Reasons

Hospital admissions from nursing homes have not previously been investigated in Norway. During 12 months all hospital admissions (acute and elective) from 32 nursing homes in Bergen were recorded via the Norwegian ambulance register. The principal diagnosis made during the stay, length of stay, and the ward were sourced from the hospitals data register and data were merged. Altogether 1,311 hospital admissions were recorded during the 12 months. Admissions from nursing homes made up 6.1% of the total number of admissions to medical wards, while for surgical wards they made up 3.8%. Infections, fractures, cardiovascular and gastri-related diagnoses represented the most frequent admission diagnoses. Infections accounted for 25.0% of admissions, including 51.0% pneumonias. Of all the admissions, fractures were the cause in 10.2%. Of all fractures, hip fractures represented 71.7. The admission rate increased as the proportion of short-term beds increased, and at nursing homes with short-term beds, admissions increased with increasing physician coverage. Potential reductions in hospitalizations for infections from nursing homes may play a role to reduce pressure on medical departments as may fracture prevention. Solely increasing physician coverage in nursing homes will probably not reduce the number of hospitalizations.

Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care.

BackgroundIn Central Norway a generic care pathway was developed in collaboration between general hospitals and primary care with the intention of implementing it into everyday practice. The care pathway targeted elderly patients who were in need of home care services after discharge from hospital. The aim of the present study was to investigate the implementation process of the care pathway by comparing the experiences of health care professionals and managers in home care services between the participating municipalities.MethodsThis was a qualitative comparative process evaluation using data from individual and focus group interviews. The Normalization Process Theory, which provides a framework for understanding how a new intervention becomes part of normal practice, was applied in our analysis.ResultsIn all of the municipalities there were expectations that the generic care pathway would improve care coordination and quality of follow-up, but a substantial amount of work was needed to make the regular home care staff understand how to use the care pathway. Other factors of importance for successful implementation were involvement of the executive municipal management, strong managerial focus on creating engagement and commitment among all professional groups, practical facilitation of work processes, and a stable organisation without major competing priorities. At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills.ConclusionThe generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organisation of home care services. However, implementation of this complex intervention in full-time running organisations was demanding and required comprehensive and prolonged efforts in all levels of the organisation. Studies on implementation of such complex interventions should therefore have a long follow-up time to identify whether the intervention becomes integrated into everyday practice.

Psychoactive drugs in seven nursing homes

AIMS We wanted to pinpoint any differences in treatment between participating nursing homes, investigate which drugs are currently prescribed most frequently for long-term patients in nursing homes, estimate prevalence of administration for the following drug groups: neuroleptics, antidepressants, antidementia agents, opioids and the neuroleptics/anti-Parkinsons drug combination, and study comorbidity correlations. We also wanted to study differences in the administration of medications to patients with reduced cognitive functions in relation to those with normal cognition. METHODS Information about 513 patients was collected from seven nursing homes in the city of Bergen, Norway, during the period March-April 2008. This consisted of copying personal medication records, weighing, recording the previous weight from records, electrocardiography, anamnestic particulars of any stroke suffered, recording if there is cognitive impairment or not and analyzing a standardized set of blood samples. RESULTS Considerable treatment differences existed between nursing homes, both percentage patients and Defined Daily Dosages. Patients with reduced cognitive functions were prescribed less drugs in general, except neuroleptics. Of all patients, 41.5% were given antidepressants, 24.4% neuroleptics, 22.0% benzodiazepines, 8.0% anticholinesterases and 5.0% memantine. The ratio of traditional to atypical neuroleptics was 122:23. In all, 30.0% of the patients taking neuroleptics were on more than one drug and 35.0% of the patients had opioids by way of regular or as-needed drugs, ratio 14.6%:28.7%. Of 146 patients on neuroleptics, five patients had anti-Parkinsons drugs too. The average use of regular drugs for patient with intact cognition was 7.1 drugs, and for patients with reduced cognitive functions 5.7 drugs. CONCLUSIONS There are differences in treatment with psychoactive drugs between nursing homes. Patients with reduced cognitive functions receive less cardiovascular drugs than patients with normal cognition. The reason for this still remains unclear. Improvement strategies are needed. The proportion of patients per institution on selected drugs can serve as a feedback parameter in quality systems.