Hilde Lurås

Cost-effectiveness in fall prevention for older women

Aims: The aim of this study was to estimate the cost-effectiveness of implementing an exercise-based fall prevention programme for home-dwelling women in the !80-year age group in Norway. Methods: The impact of the home-based individual exercise programme on the number of falls is based on a New Zealand study. On the basis of the cost estimates and the estimated reduction in the number of falls obtained with the chosen programme, we calculated the incremental costs and the incremental effect of the exercise programme as compared with no prevention. The calculation of the average healthcare cost of falling was based on assumptions regarding the distribution of fall injuries reported in the literature, four constructed representative case histories, assumptions regarding healthcare provision associated with the treatment of the specified cases, and estimated unit costs from Norwegian cost data. We calculated the average healthcare costs per fall for the first year. Results: We found that the reduction in healthcare costs per individual for treating fall-related injuries was 1.85 times higher than the cost of implementing a fall prevention programme. Conclusions: The reduction in healthcare costs more than offset the cost of the prevention programme for women aged !80 years living at home, which indicates that health authorities should increase their focus on prevention. The main intention of this article is to stipulate costs connected to falls among the elderly in a transparent way and visualize the whole cost picture. Cost-effectiveness analysis is a health policy tool that makes politicians and other makers of health policy conscious of this complexity.

Economic motives and professional norms: the case of general medical practice

Professional norms are supposed to have a central role in the allocation of resources when consumers have inferior information about the characteristics of products. We argue that economic motives are nevertheless important to resource allocation when professional opinions differ. The argument is illustrated with an example from medical care. We find that physicians who experience a shortage of patients have higher income, longer and more frequent consultations and more laboratory tests per listed person than their unconstrained colleagues.

Waiting time as a competitive device: an example from general medical practice.

From a theoretical model we predict that only physicians with quality characteristics perceived as inferior by patients are willing to embark on waiting time reductions. Because of variation in these quality characteristics among physicians, market equilibrium is likely to show a range of waiting times for physician services. This hypothesis is supported by results from a study of Norwegian general practitioners. Since the waiting time offered by a physician influences the number of patient-initiated consultations, a policy implication of our study is that the distinction between patient-initiated and physician-initiated consultations may be less clear-cut than often assumed in the literature.

Care challenges for informal caregivers of chronically ill lung patients: Results from a questionnaire survey

Aims: The article aims to answer who the informal caregivers of patients with chronic obstructive pulmonary disease (COPD) are, what kind of help they provide, and how they experience providing help to the patient. Method: Data from a questionnaire survey to next of kin of COPD patients carried through in Norway in December 2009 and January 2010 is explored. Result: About 70% of the patients have one or more informal caregivers, and a majority of the caregivers is the patient’s spouse, most often a wife. The help provided is, to a large extent, practical help like housework, garden work, and shopping. Another important support is to accompany the patient to health care. About 45% of the caregivers are part of the work force. Rather few of the respondents experience the caregiving as so demanding that they have chosen to work part-time or quit working. The most demanding part of being an informal caregiver is an overall worrying for the patient. Conclusions: Paid sick leaves for caregivers that are employed, and hospital-at-home programmes that provide education and surveillance to the patient and his/her family through different phases of the illness, are policy means that both can help the informal caregivers to manage daily life and reduce the pressure on the formal healthcare and long-term care services in the future.

The association between patient shortage and patient satisfaction with general practitioners

Objective.The aim of the study was to explore whether or not the influx of patients to a GPs practice is associated with satisfaction with the GP. Design. Persons in the Norwegian Living Condition Survey answered a questionnaire on satisfaction with their GP. The data on satisfaction were merged with registered information on the GPs and the GPs’ patient lists from the National Insurance Administration, with registered information on the samples sociodemographic background, and on their resident municipality from Statistics Norway. Setting. A representative sample of 2326 persons answered the questionnaire. This constituted persons in the survey who had visited their GP during the last six months. Main outcome measure. Satisfaction with the GPs interpersonal skills, the GPs medical skills, the GPs use of time, general accessibility to the GP, and the GPs role as a gatekeeper. Results. Persons listed with a GP who experience patient shortage were less satisfied than others along four dimensions of satisfaction: the GPs interpersonal skills, the GPs medical skills, the GPs referral practices, and the consultation lengths the GP offered. The GPs age and gender, characteristics of the patient, and characteristics of the organization of primary care had minor influence. Conclusion. Whether or not a GP experiences patient shortage is associated with patient satisfaction. Whether or not the lower patient satisfaction is a result of patient shortage or vice versa is not known.

The effect of activity-based financing on hospital length of stay for elderly patients suffering from heart diseases in Norway.

BackgroundWhether activity-based financing of hospitals creates incentives to treat more patients and to reduce the length of each hospital stay is an empirical question that needs investigation. This paper examines how the level of the activity-based component in the financing system of Norwegian hospitals influences the average length of hospital stays for elderly patients suffering from ischemic heart diseases. During the study period, the activity-based component changed several times due to political decisions at the national level.MethodsThe repeated cross-section data were extracted from the Norwegian Patient Register in the period from 2000 to 2007, and included patients with angina pectoris, congestive heart failure, and myocardial infarction. Data were analysed with a log-linear regression model at the individual level.ResultsThe results show a significant, negative association between the level of activity-based financing and length of hospital stays for elderly patients who were suffering from ischemic heart diseases. The effect is small, but an increase of 10 percentage points in the activity-based component reduced the average length of each hospital stay by 1.28%.ConclusionsIn a combined financing system such as the one prevailing in Norway, hospitals appear to respond to economic incentives, but the effect of their responses on inpatient cost is relatively meagre. Our results indicate that hospitals still need to discuss guidelines for reducing hospitalisation costs and for increasing hospital activity in terms of number of patients and efficiency.

Patient switching in general practice.

Patients switching physicians involves costs to the patients because of less continuity of care. From a theoretical model we derive that inferior physician quality as perceived by patients, implies patient shortage for the physician and more patients switching physicians. By means of a unique panel data set covering the entire population of Norwegian general practitioners (GPs) and estimation methods that adjust for potential endogeneities, we find that the occurrence of patient shortage increases the proportion of patients switching physicians by 50%. A competing hypothesis that GPs with a shortage of patients experience less switching because of superior access is rejected by data. To assist patients in making informed decisions, we suggest that the number of switches a physician experiences should be made public.

Dual job holding general practitioners: the effect of patient shortage

In 2001, a listpatient system with capitation payment was introduced in Norwegian general practice. After an allocation process where each inhabitant was listed with a general practitioner (GP), a considerable share of the GPs got fewer persons listed than they would have preferred. We examine whether GPs who experience a shortage of patients to a larger extent than other GPs seek to hold a second job in the community health service even though the wage rate is low compared with the wage rate in general practice. Assuming utility maximization, we model the effect of patient shortage on a GPs decision to contract for a second job in the community health service. The model predicts a positive relationship between patient shortage and participation in the community health service. This prediction is tested by means of censored regression analyses, taking account of labour supply as a censored variable. We find a significant effect of patient shortage on the number of hours the GPs supply to community health service. The estimated marginal effect is 1.72 hours per week.

Referrals from nursing home to hospital: Reasons, appropriateness and costs

Background: Nursing home residents represent a frail and multimorbid group of patients. The rationality of the hospitalisation of nursing home patients has therefore been questioned. Objective: To investigate hospital referrals of nursing home patients in the municipality of Stavanger, Norway and identify the number of inappropriate referrals and costs. Methods: The number of referrals was retrospectively identified by the emergency dispatch centre in the 18 municipalities of South Rogaland in 2011. For the municipality of Stavanger, referring instance, reason for referral, purpose of referral, the existence of an advance care plan, and appropriateness were assessed. Total costs and costs for inappropriate referrals were estimated. Results: In Stavanger there were 0.38 hospital referrals per nursing home bed per year as compared to 0.60 in the surrounding municipalities. Of 359 referrals, 78.6% resulted in an in-hospital stay, in-hospital mortality rate was 7.8%, and 7% were assessed as being inappropriate. The costs per referral were estimated to be €6198. Conclusion: Stavanger had a lower referral rate than the surrounding municipalities. The results also show that the in-hospital mortality rate and the share of inappropriate referrals were low compared to other studies in the field. Further research is needed in order to evaluate which interventions are effective in improving medical care at nursing homes and thus reduce referral rates.

One-year health and care costs after hip fracture for home-dwelling elderly patients in Norway: Results from the Trondheim Hip Fracture Trial

Aim: The aim of this study was to estimate the one-year health and care costs related to hip fracture for home-dwelling patients aged 70 years and older in Norway, paying specific attention to the status of the patients at the time of fracture and cost differences due to various patient pathways after fracture. Methods: Data on health and care service provision were extracted from hospital and municipal records and from national registries; data on unit costs were collected from the municipalities, hospital administrations and previously published studies. Four different patient pathways were identified and the total costs for subgroups of patients according to age, sex, fracture type and instrumental activity of daily living at fracture incidence were calculated. Descriptive statistics were used to identify cost estimates. Results: The mean total one-year costs per patient were EUR 68,376 and the costs for patients alive one year after hip fracture were EUR 71,719. The patients’ age and pre-fracture functional status contributed most to the total cost. Conclusions: On average, care costs accounted for more than 50% of the total cost; even for patients with good functional status before hip fracture, care costs accounted for 40% of the total cost compared with hospital costs of 38%. To reduce the financial costs of hip fractures in the care sector, the results point to the importance of preventive programmes to reduce the risk of hip fracture, but also to the importance of comprehensive geriatric care in the initial phase after a hip fracture.