Helge Garåsen

The quality of communication about older patients between hospital physicians and general practitioners: a panel study assessment

BackgroundOptimal care of patients is dependent on good professional interaction between general practitioners and general hospital physicians. In Norway this is mainly based upon referral and discharge letters. The main objectives of this study were to assess the quality of the written communication between physicians and to estimate the number of patients that could have been treated at primary care level instead of at a general hospital.MethodsThis study comprised referral and discharge letters for 100 patients above 75 years of age admitted to orthopaedic, pulmonary and cardiological departments at the city general hospital in Trondheim, Norway. The assessments were done using a Delphi technique with two expert panels, each with one general hospital specialist, one general practitioner and one public health nurse using a standardised evaluation protocol with a visual analogue scale (VAS). The panels assessed the quality of the description of the patients actual medical condition, former medical history, signs, medication, Activity of Daily Living (ADL), social network, need of home care and the benefit of general hospital care.ResultsWhile information in the referral letters on actual medical situation, medical history, symptoms, signs and medications was assessed to be of high quality in 84%, 39%, 56%, 56% and 39%, respectively, the corresponding information assessed to be of high quality in discharge letters was for actual medical situation 96%, medical history 92%, symptoms 60%, signs 55% and medications 82%. Only half of the discharge letters had satisfactory information on ADL. Some two-thirds of the patients were assessed to have had large health benefits from the general hospital care in question. One of six patients could have been treated without a general hospital admission. The specialists assessed that 77% of the patients had had a large benefit from the general hospital care; however, the general practitioners assessment was only 59%. One of four of the discharge letters did not describe who was responsible for follow-up care.ConclusionIn this study from one general hospital both referral and discharge letters were missing vital medical information, and referral letters to such an extent that it might represent a health hazard for older patients. There was also low consensus between health professionals at primary and secondary level of what was high benefit of care for older patients at a general hospital.

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.

Long-term patients’ outcomes after intermediate care at a community hospital for elderly patients: 12-month follow-up of a randomized controlled trial

Background: Developing a better understanding of if, and when, patients need care at a general hospital is an urgent challenge, as the proportion of general hospital beds being occupied by older patients is continuously increasing. Methods: In a randomized controlled trial, of 142 patients aged 60 years or more admitted to a city general hospital due to acute illness or exacerbation of a chronic disease, 72 (intervention group) were randomized to intermediate care at a community hospital, and 70 (general hospital group) to further general hospital care. The patients were followed up for 12 months. The need for long-term home care and nursing homes, mortality and the number of admissions and days in general hospital for all diseases were monitored. Results: Thirty-five patients, 13 (18.1%) of the patients included in the intervention group and 22 (31.4%) in the general hospital group, died within 12 months (p=0.03). Patients in the intervention group were observed for a longer period of time than those in the general hospital group; 335.7 (95% confidence interval (CI) 312.0—359.4) vs. 292.8 (95% CI 264.1—321.5) days (p=0.01). There were statistically no differences in the need for long-term primary-level care or in the number of admissions or days spent in general hospital beds. Conclusions: Intermediate care at the community hospital in Trondheim is an equal alternative to ordinary prolonged care at the city general hospital, as fewer patients were in need of community care services, and significantly fewer patients died during the 12-month follow-up time.

Effects and barriers to deployment of telehealth wellness programs for chronic patients across 3 European countries

BACKGROUND Benefits of cardiopulmonary rehabilitation (CPR) in patients with chronic obstructive pulmonary disease (COPD) are well established, but long-term sustainability of training-induced effects and its translation into healthy lifestyles are unsolved issues. It is hypothesized that Integrated Care Services supported by Information and Communication Technologies (ICS-ICT) can overcome such limitations. In the current study, we explored 3 ICS-ICT deployment experiences conducted in Barcelona, Trondheim and Athens. METHODS In the 3 sites, a total of 154 patients completed an 8-week supervised CPR program. Thereafter, they were allocated either to an ICS-ICT group or to usual care (CPR + UC) during a follow-up period of at least 12 months with assessment of 6-min walking test (6MWT) as main outcome variable at all time points in the 3 sites. Because real deployment was prioritized, the interventions were adapted to site heterogeneities. RESULTS In the ICS-ICT group from Barcelona (n = 77), the use of the personal health folder (PHF) was the cornerstone technological tool to empower COPD patients for self-management showing high applicability and user-acceptance. Long-term sustainability of training-induced increase in exercise capacity was observed in ICS-ICT compared to the control group (p = 0.01). Likewise, ICS-ICT enhanced the activities domain of the SGRQ (p < 0.01) and daily physical activity (p = 0.03), not seen in controls. No effects of ICS-ICT were observed in Trondheim (n = 37), nor in Athens (n = 40), due to technological and/or organizational limitations. CONCLUSIONS The study results suggest the potential of the ICS-ICT Barcelonas approach to enhance COPD management. Moreover, it allowed identification of the factors limiting transferability to the other sites. The research prompts the need for large multicenter trials specifically designed to assess effectiveness, efficiencies and transferability of this type of intervention.

Tuberculosis screening and follow-up of asylum seekers in Norway: a cohort study.

BackgroundAbout 80% of new tuberculosis cases in Norway occur among immigrants from high incidence countries. On arrival to the country all asylum seekers are screened with Mantoux test and chest x-ray aimed to identify cases of active tuberculosis and, in the case of latent tuberculosis, to offer follow-up or prophylactic treatment.We assessed a national programme for screening, treatment and follow-up of tuberculosis infection and disease in a cohort of asylum seekers.MethodsAsylum seekers ≥ 18 years who arrived at the National Reception Centre from January 2005 to June 2006, were included as the total cohort. Those with a Mantoux test ≥ 6 mm or positive x-ray findings were included in a study group for follow-up.Data were collected from public health authorities in the municipality to where the asylum seekers had moved, and from hospital based internists in case they had been referred to specialist care.Individual subjects included in the study group were matched with the Norwegian National Tuberculosis Register which receive reports of everybody diagnosed with active tuberculosis, or who had started treatment for latent tuberculosis.ResultsThe total cohort included 4643 adult asylum seekers and 97.5% had a valid Mantoux test. At least one inclusion criterion was fulfilled by 2237 persons. By end 2007 municipal public health authorities had assessed 758 (34%) of them. Altogether 328 persons had been seen by an internist. Of 314 individuals with positive x-rays, 194 (62%) had seen an internist, while 86 of 568 with Mantoux ≥ 15, but negative x-rays (16%) were also seen by an internist. By December 31st 2006, 23 patients were diagnosed with tuberculosis (prevalence 1028/100 000) and another 11 were treated for latent infection.ConclusionThe coverage of screening was satisfactory, but fewer subjects than could have been expected from the national guidelines were followed up in the community and referred to an internist. To improve follow-up of screening results, a simplification of organisation and guidelines, introduction of quality assurance systems, and better coordination between authorities and between different levels of health care are all required.

The Self-Transcendence Scale: An Investigation of the Factor Structure Among Nursing Home Patients

Purpose: Self-transcendence, the ability to expand personal boundaries in multiple ways, has been found to provide well-being. The purpose of this study was to examine the dimensionality of the Norwegian version of the Self-Transcendence Scale, which comprises 15 items. Background: Reed’s empirical nursing theory of self-transcendence provided the theoretical framework; self-transcendence includes an interpersonal, intrapersonal, transpersonal, and temporal dimension. Design: Cross-sectional data were obtained from a sample of 202 cognitively intact elderly patients in 44 Norwegian nursing homes. Results: Exploratory factor analysis revealed two and four internally consistent dimensions of self-transcendence, explaining 35.3% (two factors) and 50.7% (four factors) of the variance, respectively. Confirmatory factor analysis indicated that the hypothesized two- and four-factor models fitted better than the one-factor model (cx2, root mean square error of approximation, standardized root mean square residual, normed fit index, nonnormed fit index, comparative fit index, goodness-of-fit index, and adjusted goodness-of-fit index). Conclusions: The findings indicate self-transcendence as a multifactorial construct; at present, we conclude that the two-factor model might be the most accurate and reasonable measure of self-transcendence. Implications: This research generates insights in the application of the widely used Self-Transcendence Scale by investigating its psychometric properties by applying a confirmatory factor analysis. It also generates new research-questions on the associations between self-transcendence and well-being.

The role of entry screening in case finding of tuberculosis among asylum seekers in Norway

BackgroundMost new cases of active tuberculosis in Norway are presently caused by imported strains and not transmission within the country. Screening for tuberculosis with a Mantoux test of everybody and a chest X-ray of those above 15 years of age is compulsory on arrival for asylum seekers.We aimed to assess the effectiveness of entry screening of a cohort of asylum seekers. Cases detected by screening were compared with cases detected later. Further we have characterized cases with active tuberculosis.MethodsAll asylum seekers who arrived at the National Reception Centre between January 2005 - June 2006 with an abnormal chest X-ray or a Mantoux test ≥ 6 mm were included in the study and followed through the health care system. They were matched with the National Tuberculosis Register by the end of May 2008.Cases reported within two months after arrival were defined as being detected by screening.ResultsOf 4643 eligible asylum seekers, 2237 were included in the study. Altogether 2077 persons had a Mantoux ≥ 6 mm and 314 had an abnormal chest X-ray. Of 28 cases with tuberculosis, 15 were detected by screening, and 13 at 4-27 months after arrival. Abnormal X-rays on arrival were more prevalent among those detected by screening. Female gender and Somalian origin increased the risk for active TB.ConclusionIn spite of an imperfect follow-up of screening results, a reasonable number of TB cases was identified by the programme, with a predominance of pulmonary TB.

Screening and treatment of latent tuberculosis in a cohort of asylum seekers in Norway.

Aims: Asylum seekers are screened for tuberculosis at entry to Norway. We aimed to assess follow-up of screening results at different healthcare levels in relation to demographics, screening results and organizational factors, and how this influenced treatment of latent tuberculosis. Methods: All asylum seekers ≥18 years with a Mantoux test ≥6 mm or positive x-ray findings who arrived at the National Reception Centre from January 2005 to June 2006, were included. Data were collected from public health authorities in the municipality where the asylum seekers had moved, and from internists in case they had been referred to a specialist. Specialists are responsible for treating latent tuberculosis. Individual subjects were matched with the National Tuberculosis Register to which everybody who had started treatment for latent tuberculosis was reported. Results: Of 4,643 asylum seekers, 2,237 fulfilled the inclusion criteria. By May 2008, 30 persons had started treatment for latent TB, a median of 17 months (range 3—36) after arrival. A Mantoux test ≥15 mm on arrival was significantly associated with treatment. Demographic factors influenced follow-up in primary healthcare while screening results did not. Referral to specialist was related to screening results. Several specialists were reluctant to diagnose and treat latent tuberculosis and to treat persons without a permanent visa in particular. Conclusions: Just 1% of the study group received treatment for latent tuberculosis and with a long time delay. The reason for this may be organizational factors affecting follow-up and referral and specialists not following current guidelines.

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.

Health care for the elderly — perspectives in relation to implementation of results from intervention studies in Norway and Denmark:

This editorial summarizes some examples of intervention studies from Norway and Denmark in relation to organizing health care for the elderly Never before have so many older people in Western countries had so many years with a high level of functional ability as older people have today. The cause of this improvement is complex – social and economic circumstances are better, and health care in relation to the technical and medical possibilities is much better. An increasing number of older people have an acceptable life despite one or more chronic diseases. At the same time, health care and welfare services are under severe financial pressure. There is a continuously ongoing process towards more outpatient care, fewer hospital beds and a reduction in days of inpatient care, with a tendency towards inpatient care concentrating on acute incidents and increasingly leaving the rehabilitation and follow-up care to the primary health care services [1]. Complex intervention can help elderly people to live safely and independently, and can be tailored to meet individuals’ needs and preferences [2]. An optimal strategy implies a multisectoral collaboration – integrated health care. Despite this knowledge there is still a lack of integration – patients are moved quickly through the emergency system towards discharge – ‘‘a hit and run system’’ – with poor communication with community services [1]. Preventive home visits – evidence and the law in Denmark