Anne Helen Hansen

Socio-economic inequalities in health care utilisation in Norway: a population based cross-sectional survey

BackgroundNorway provides universal health care coverage to all residents, but socio-economic inequalities in health are among the largest in Europe. Evidence on inequalities in health care utilisation is sparse, and the aim of this population based study was to investigate socio-economic inequalities in the utilisation of health care services in Tromsø, Norway.MethodsWe used questionnaire data from the cross-sectional Tromsø Study, conducted in 2007–8. All together 12,982 persons aged 30–87 years participated with the response rate of 65.7%. This is slightly more than one third of the total population (33.8%) in the mentioned age group in Tromsø municipality. By logistic regression analyses we studied associations between household income, education and self-rated occupational status and the utilisation of general practitioner, somatic and psychiatric specialist outpatient services. The outcome variables were probability and frequency of use during the previous 12 months. Analyses were stratified by gender and adjusted for age, marital status, and self-rated health.ResultsSelf-rated health was the dominant predictor of health care utilisation. Women’s probability of visiting a general practitioner did not vary by socio-economic status, but high income was associated with less frequent use (odds ratio [OR] for trend 0.89, 95% confidence interval [CI] 0.81-0.98). In men, high income predicted lower probability and frequency of general practitioner utilisation (OR for trend 0.85, CI 0.76-0.94, and 0.86, 0.78-0.95, respectively). Women’s probability of visiting a somatic specialist increased with higher income (OR for trend 1.11, CI 1.01-1.21) and higher education (OR for trend 1.27, CI 1.16-1.39). We found the same trends for men, though significant only for education (OR for trend 1.14, CI 1.05-1.25). The likelihood of visiting psychiatric specialist services increased with higher education and decreased with higher income in women (OR for trend 1.57, CI 1.24-1.98, and 0.69, 0.56-0.86, respectively), but did not vary significantly by socio-economic variables in men. Higher income predicted more frequent use of psychiatric specialist services in men (OR for trend 2.02, CI 1.12-3.63).ConclusionsThis study revealed important inequalities in the utilisation of health care services in Norway, inequalities which may contribute to sustaining inequalities in health outcomes.

Continuity of GP care is related to reduced specialist healthcare use: a cross-sectional survey.

BACKGROUND Continuity of GP care is associated with reduced hospitalisations, but solid documentation of its relationship to use of outpatient specialist services is lacking. AIM To test the association between continuity of GP care and use of inpatient and outpatient specialist services. DESIGN AND SETTING A cross-sectional population-based study with questionnaire data from the sixth Tromsø Study (2007-2008). METHOD Descriptive statistics and two sample t-test were used to estimate specialist healthcare use according to duration of the GP-patient relationship. Logistic regression analysis was used to assess associations between duration and intensity of the GP-patient relationship and use of specialist care. Analyses were adjusted for sex, age, marital status, income, education, and self-rated health, and also stratified by self-rated health and age. RESULTS Of 10,624 eligible GP users, 85% had seen the same GP for >2 years. The probability of visiting outpatient specialist services was significantly lower among these participants compared to those with a shorter GP relationship (odds ratio [OR] = 0.81, 95% confidence interval [95% CI] = 0.71 to 0.92). Similar findings were found for hospitalisations (OR = 0.76, 95% CI = 0.64 to 0.90). Stratified analyses revealed that these associations were not dependent on self-rated health or age. The probability of specialist use increased for the frequent GP users. CONCLUSION Continuity of GP care is associated with reduced use of outpatient specialist services and hospitalisations. Healthcare providers and policymakers who wish to limit use of specialist health care may do well to perform and organise health services in ways that support continuity in general practice.

The ecology of medical care in Norway: wide use of general practitioners may not necessarily keep patients out of hospitals

Background Our aim was to investigate the pattern of self reported symptoms and utilisation of health care services in Norway. Design and Methods With data from the cross-sectional Tromsø Study (2007-8), we estimated population proportions reporting symptoms and use of seven different health services. By logistic regression we estimated differences according to age and gender. Results In this study 12,982 persons aged 30-87 years participated, constituting 65.7% of those invited. More than 900/1000 reported symptoms or health problems in a year as well as in a month, and 214/1000 and 816/1000 visited a general practitioner once or more in a month and a year, respectively. The corresponding figures were 91/1000 and 421/1000 for specialist outpatient visits, and 14/1000 and 116/1000 for hospitalisations. Physiotherapists were visited by 210/1000, chiropractors by 76/1000, complementary and alternative medical providers by 127/1000, and dentists by 692/1000 in a year. Women used most health care services more than men, but genders used hospitalisations and chiropractors equally. Utilisation of all services increased with age, except chiropractors, dentists and complementary and alternative medical providers. Conclusions Almost the entire population reported health related problems during the previous year, and most residents visited a general practitioner. Yet there were high rates of inpatient and outpatient specialist utilisation. We suggest that wide use of general practitioners may not necessarily keep patients out of specialist care and hospitals. Acknowledgments the authors would like to thank Tor Anvik for a significant contribution in developing the idea for the study, Tom Wilsgård for useful discussions about the statistical analyses and Jarl-Stian Olsen for graphic design of the figures. They would also thank the people of Tromsø and The Tromsø Study for giving data to this study. Northern Norway Regional Health Authority and The University of Tromsø funded this research.

Factors facilitating patient satisfaction among women with medically unexplained long-term fatigue: A relational perspective:

Bodily conditions that are difficult to identify, explain and treat with the aid of medical knowledge and technology appear to be particularly challenging to medical encounters. Patients are often dissatisfied with the help they receive, and they often experience that their medical needs are not met. To explore factors facilitating patient satisfaction among patients with a medically unexplained condition, we ask: what is the importance of individual versus relational factors in facilitating patient satisfaction in clinical encounters between general practitioners (GPs) and women with medically unexplained long-term fatigue? We approach this question through a statistical analysis of survey data collected from a net sample of 431 women recruited through a patient organisation for people suffering from myalgic encephalomyelitis in 2013. Participants were asked about their experiences with general practitioners in the Norwegian national health system in two different phases: shortly after illness onset, and current regular general practitioner last 12 months. The questions evolved around themes concerning shared understanding and decision making, being taken seriously, being paid due respect and being treated as an equal partner. Through descriptive statistics and multivariable logistic regression analyses, we explored how their experiences were related to individual and relational factors, respectively. Free-text comments from the questionnaires were used while interpreting the results. The analysis illuminates that relational aspects in medical encounters between GPs and ME patients, especially continuity, congruence in doctor–patient views and being seen by a specialist, are important catalysts of patient satisfaction. The probability of being satisfied with the initial investigation was more than six times higher in women who were referred to specialists, compared to those who were not. We conclude that continuity of care and experiences of being in a partnership that operates on a common ground – a shared understanding of the patient’s illness – foster patient satisfaction among women with medically unexplained long-term fatigue.

Gender differences in the use of psychiatric outpatient specialist services in Tromsø, Norway are dependent on age: a population-based cross-sectional survey.

BackgroundOverall, men are less likely than women to seek health care services for mental health problems, but differences between genders in higher age groups are equivocal. The aim of the current study was to investigate the association between gender and the use of psychiatric outpatient specialist services in Norway, both in a general population and in a subpopulation with self-reported anxiety and/or depression.MethodsUsing questionnaires from 12,982 participants (30–87 years) in the cross-sectional sixth Tromsø Study (2007-8) we estimated proportions reporting anxiety/depression, and proportions using psychiatric outpatient specialist services in a year. By logistic regressions we studied the association between gender and the use of psychiatric outpatient specialist services. Analyses were adjusted for age, marital status, income, education, self-reported degree of anxiety/depression, and GP visits last year. Analyses were also performed for genders separately.ResultsAnxiety/depression was reported by 21.5 % of women and 12.3 % of men in the general population. Visits to psychiatric outpatient services during one year were reported by 4.6 % of women and 3.3 % of men. The general population’s probability of a visit was significantly lower among men compared to women in ages 30–49 years (odds ratio [OR] 0.58, confidence interval [CI] 0.39–0.84, p-value [p] = 0.004), whereas men used services slightly more than women in ages 50 years and over (OR 1.36, CI 1.00–1.83, p = 0.047). Among those with anxiety/depression 13.5 % of women and 10.5 % of men visited psychiatric outpatient services in a year. We found no statistically significant gender differences in the use of services in this subgroup. Other factors associated with services use in women with anxiety/depression were higher education, more severe anxiety/depression, and GP visits the last year, whereas in men only a more severe anxiety/depression was associated with psychiatric outpatient visits. Overall, the use of services decreased with higher age.ConclusionsMost people with self-reported anxiety/depression did not visit specialist outpatient clinics. This applies in particular to men aged 30–49 years, older individuals, and individuals with lower education. Gender differences in the use of services in the general population were dependent on age, whereas in the subgroup with anxiety/depression gender differences were not confirmed.

Experiences of general practitioner continuity among women with chronic fatigue syndrome/myalgic encephalomyelitis: a cross-sectional study.

BackgroundContinuity of care is important for patients with chronic illness in need of coordinated healthcare services from multiple providers. Little is known about how patients with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) experience continuity of GP care.This study explores how women with CFS/ME experience GP care across the three dimensions of continuity: informational, management, and relational continuity.MethodsThis cross-sectional study uses questionnaire data collected from members of The Norwegian ME Association. Descriptive statistics and logistic regressions were used to estimate experiences of continuity, and associations with age, education, self-rated degree of CFS/ME, duration of the GP relation (GP duration), and number of GP visits for CFS/ME-related issues during the previous year (GP frequency).ResultsAlmost two-thirds of participants reported positive experiences across all three dimensions of GP continuity of care; 64.4% for informational, 64.1% for management, and 77.2% for relational continuity. Lower educational attainment was associated with more negative experiences of informational continuity (primary school only compared to university educated: odds ratio [OR] 0.12, confidence interval [CI] 0.03–0.49, p = 0.003). Compared to participants aged 40–59 years, those aged 60+ years were significantly less likely to have experienced poor (negative) management continuity (OR 0.25, CI 0.09–0.76, p = 0.014). A GP relationship of three or more years was associated with positive experiences of relational continuity (OR 2.32, CI 1.09–4.95, p = 0.030). Compared to those with moderate CFS/ME, those who graded their CFS/ME as severe or very severe were significantly more likely to have negative experiences of relational continuity (OR 0.38, CI 0.14–0.99, p = 0.047).ConclusionsA large proportion of participants experienced all three aspects of continuity of GP care (especially the relational dimension) positively. Informational and management continuity scores were moderately lower. Our results suggest greater emphasis on information giving, feedback, and better coordination of care to be good strategies for practice improvement for this patient group.

Design and Development of a Context-Aware Knowledge-Based Module for Identifying Relevant Information and Information Gaps in Patients With Type 1 Diabetes Self-Collected Health Data

Background Patients with diabetes use an increasing number of self-management tools in their daily life. However, health institutions rarely use the data generated by these services mainly due to (1) the lack of data reliability, and (2) medical workers spending too much time extracting relevant information from the vast amount of data produced. This work is part of the FullFlow project, which focuses on self-collected health data sharing directly between patients’ tools and EHRs. Objective The main objective is to design and implement a prototype for extracting relevant information and documenting information gaps from self-collected health data by patients with type 1 diabetes using a context-aware approach. The module should permit (1) clinicians to assess the reliability of the data and to identify issues to discuss with their patients, and (2) patients to understand the implication their lifestyle has on their disease. Methods The identification of context and the design of the system relied on (1) 2 workshops in which the main author participated, 1 patient with type 1 diabetes, and 1 clinician, and (2) a co-design session involving 5 patients with type 1 diabetes and 4 clinicians including 2 endocrinologists and 2 diabetes nurses. The software implementation followed a hybrid agile and waterfall approach. The testing relied on load, and black and white box methods. Results We created a context-aware knowledge-based module able to (1) detect potential errors, and information gaps from the self-collected health data, (2) pinpoint relevant data and potential causes of noticeable medical events, and (3) recommend actions to follow to improve the reliability of the data issues and medical issues to be discussed with clinicians. The module uses a reasoning engine following a hypothesize-and-test strategy built on a knowledge base and using contextual information. The knowledge base contains hypotheses, rules, and plans we defined with the input of medical experts. We identified a large set of contextual information: emotional state (eg, preferences, mood) of patients and medical workers, their relationship, their metadata (eg, age, medical specialty), the time and location of usage of the system, patient-collected data (eg, blood glucose, basal-bolus insulin), patients’ goals and medical standards (eg, insulin sensitivity factor, in range values). Demonstrating the usage of the system revealed that (1) participants perceived the system as useful and relevant for consultation, and (2) the system uses less than 30 milliseconds to treat new cases. Conclusions Using a knowledge-based system to identify anomalies concerning the reliability of patients’ self-collected health data to provide information on potential information gaps and to propose relevant medical subjects to discuss or actions to follow could ease the introduction of self-collected health data into consultation. Combining this reasoning engine and the system of the FullFlow project could improve the diagnostic process in health care.

Prevalence and predictors of complementary and alternative medicine use among people with coronary heart disease or at risk for this in the sixth Tromsø study: a comparative analysis using protection motivation theory

BackgroundEngagement in healthy lifestyle behaviors, such as healthy diet and regular physical activity, are known to reduce the risk of developing coronary heart disease (CHD). Complementary and alternative medicine (CAM) is known to be associated with having a healthy lifestyle. The primary aim of this study was to examine the prevalence and predictors of CAM use in CHD patients, and in those without CHD but at risk for developing CHD, using Protection Motivation Theory (PMT) as a guiding conceptual framework.MethodQuestionnaire data were collected from 12,981 adult participants in the cross-sectional sixth Tromsø Study (2007–8). Eligible for analyses were 11,103 participants who reported whether they had used CAM or not. Of those, 830 participants reported to have or have had CHD (CHD group), 4830 reported to have parents, children or siblings with CHD (no CHD but family risk), while 5443 reported no CHD nor family risk of CHD. We first compared the patterns of CAM use in each group, and then examined the PMT predictors of CAM use. Health vulnerability from the threat appraisal process of PMT was assessed by self-rated health and expectations for future health. Response efficacy from the coping appraisal process of PMT was assessed as preventive health beliefs and health behavior frequency.ResultsUse of CAM was most commonly seen in people with no CHD themselves, but family risk of developing CHD (35.8%), compared to people already diagnosed with CHD (30.2%) and people with no CHD nor family risk (32.1%). All four of the PMT factors; self-rated health, expectations for future health, preventive health beliefs, and the health behavior index – were predictors for CAM use in the no CHD but family risk group.ConclusionThese findings suggest that people use CAM in response to a perceived risk of developing CHD, and to prevent disease and to maintain health.