Irene Skau

Oral health-related quality of life and associated factors in Norwegian adults

Abstract Objective. To investigate associations between oral health-related quality of life assessed with the Oral Health Impact Profile (OHIP)-14 and demographic factors, number of teeth present, dental visits, dental health behaviour and self-rated oral health in a representative sample of 20–80-year-old Norwegians. Material and methods. The study was conducted in a stratified random sample of 3538 individuals. Questionnaires including questions on demographic factors, number of remaining teeth, dental visits, dental health behaviour, self-rated oral health and OHIP-14 were mailed to the sample. Bivariate and multivariate analyses were performed. Results. The response rate was 69%. The mean OHIP-14 score was 4.1 (standard deviation = 6.2). No problem was reported by 35% of the respondents. The most frequently reported problems were: physical pain (56%), psychological discomfort (39%) and psychological disability (30%). When the effect of all independent variables was analysed in multivariate analysis, self-rated oral health, frequency of dental visits, number of teeth, age and sex were significantly (P < 0.05) associated with the prevalence of having problems and frequent problems. Self-rated oral health had the strongest association with having problems [odds ratio (OR) 4.5; 95% confidence interval (CI) 3.4–6.0] and with having frequent problems (OR 4.0; 95% CI 2.7–5.8). Dental health behaviour, use of floss and toothpicks and oral rinsing were not associated with having problems related to oral quality of life in multivariate analyses. Conclusion. In this Norwegian adult sample, self-rated oral health, frequency of dental visits, number of teeth, age and sex were associated with having problems as estimated using the OHIP-14.

Incentives and remuneration systems in dental services

The aim of this study was to examine the effects of an incentive-based remuneration system on number of individuals under supervision and on quality of public dental services in Norway. The basis for the study was a natural experiment in which all public dental officers in one county were given the opportunity to renegotiate their contract from a fixed salary contract to a combined per capita and fixed salary contract. Comprehensive data were collected before and after the change. A main finding is that the transition to an incentive-based remuneration system led to an increase in the number of individuals under supervision without either a fall in quality or a patient selection effect.

Do expert patients get better treatment than others? Agency discrimination and statistical discrimination in obstetrics.

We address models that can explain why expert patients (obstetricians, midwives and doctors) are treated better than non-experts (mainly non-medical training). Models of statistical discrimination show that benevolent doctors treat expert patients better, since experts are better at communicating with the doctor. Agency theory suggests that doctors have an incentive to limit hospital costs by distorting information to non-expert patients, but not to expert patients. The hypotheses were tested on a large set of data, which contained information about the highest education of the parents, and detailed medical information about all births in Norway during the period 1967-2005 (Medical Birth Registry). The empirical analyses show that expert parents have a higher rate of Caesarean section than non-expert parents. The educational disparities were considerable 40 years ago, but have become markedly less over time. The analyses provide support for statistical discrimination theory, though agency theory cannot be totally excluded.

Services production and patient satisfaction in primary care

CONTEXT The institutional setting for the study was the primary physician service in Norway, where there is a regular general practitioner scheme. Each inhabitant has a statutory right to be registered with a regular general practitioner. There are large differences between physicians in service production. OBJECTIVE We studied whether difference in services production between physicians has an effect on how satisfied patients are with the services that are provided. METHODOLOGY Data about patient satisfaction were obtained from a survey of a representative sample of the population. We obtained data about how satisfied the respondents were with: waiting time to get an appointment, amount of time the physician spent with them, and to what extent they perceived that the physician took their medical problems seriously. The survey data were merged with data on service production for the primary physician that the respondent was registered with. Service production was measured as the number of consultations per person on the list. RESULTS There was a positive and relatively strong association between the level of service production of the general practitioners and patient satisfaction with waiting time for a consultation. There was no association between the level of service production and the two other measures of patient satisfaction. CONCLUSION The results provide evidence about one of several factors that should be taken into account when deciding on future health manpower policies with respect to primary physician services in Norway.

Do Mothers Decide?: The Impact of Preferences in Healthcare

In this study we analyze whether immigrant mothers in Norway can influence their mode of delivery. Patient preferences were measured as the rate of Caesarean section from their home country, and by a survey question measuring the extent to which people believe they have freedom of choice and control over their lives in their home country. Preferences have a causal effect on the likelihood of Caesarean section. Medical risk factors are still the most important reasons for having a Caesarean section, but our regression estimates show that a substantial share of Caesarean sections is due to preferences as well.

Specialization and competition in dental health services

The number of specialists within dental health services has increased over the last few years. This raises the issue of how the services should be organized and funded. We describe the effect of one way of organizing the services, which is by relying on competition. In Norway, some oral specialists face real competition with general dental practitioners for the same patients (prosthetists, periodontists and endodontists), while other specialists do not (orthodontists and oral surgeons). The latter specialists have skills that give them exclusive possibilities to practice their profession. We find that competition can be effective for the specialists who experience real competition with general dental practitioners for patients. In situations where real competition does not exist, specialists can obtain market power and raise their fees. Our results are based on an analysis of a representative set of data from general dental practitioners and specialists in Norway. The specialities in which practitioners can exercise market power raise challenges related to the type of public policy that can reduce this market power in an appropriate way, and without involving too large costs for the authorities.

Regionalization and Local Hospital Closure in Norwegian Maternity Care—The Effect on Neonatal and Infant Mortality

OBJECTIVE To study whether neonatal and infant mortality, after adjustments for differences in case mix, were independent of the type of hospital in which the delivery was carried out. DATA The Medical Birth Registry of Norway provided detailed medical information for all births in Norway. STUDY DESIGN Hospitals were classified into two groups: local hospitals/maternity clinics versus central/regional hospitals. Outcomes were neonatal and infant mortality. The data were analyzed using propensity score weighting to make adjustments for differences in case mix between the two groups of hospitals. This analysis was supplemented with analyses of 13 local hospitals that were closed. Using a difference-in-difference approach, the effects that these closures had on neonatal and infant mortality were estimated. PRINCIPAL FINDING Neonatal and infant mortality were not affected by the type of hospital where the delivery took place. CONCLUSION A regionalized maternity service does not lead to increased neonatal and infant mortality. This is mainly because high-risk deliveries were identified well in advance of the birth, and referred to a larger hospital with sufficient perinatal resources to deal with these deliveries.

Per capita remuneration of dentists and the quality of dental services.

OBJECTIVES The aim of this study was to examine the effects of a per capita based remuneration system on the quality of dental care. METHODS The basis for the study was a natural experiment in the county of Østfold in Norway in which all public dental officers (n = 34) were given the opportunity to renegotiate their contract from a fixed salary to a combined per capita and fixed salary contract. Quality was assessed according to three criteria: number of preventive procedures, number of under-diagnosed carious lesions and number of untreated carious lesions. This information was selected from a random sample of patient records for 18-year-olds in the autumn of 1999 (base-line data) and at the end of 2006 (final data), altogether 20 records per dentist. At the end of the period of evaluation, 26 dentists were still eligible for inclusion in the study. The data were analysed both descriptively and using multilevel difference-in-difference regression models. RESULTS The main finding was that the transition to a per capita remuneration system did not lead to under-diagnosis of carious lesions, under-treatment or less prevention. CONCLUSIONS A per capita remuneration scheme did not lead to a fall in the quality of dental care. This result must be assessed taking into account that the experiment was carried out within a publicly financed and managed dental service. Also, the incentive effect of the per capita contract was relatively weak.

Better primary physician services lead to fewer hospital admissions.

The aim of the study was to examine whether improved quality of primary physician services, measured by patient satisfaction, leads to fewer admissions to somatic hospitals. We studied differences in hospital admissions at the municipality level in Norway. In addition to the standard explanatory variables for use of hospitals—gender, age, socio-economic status and travelling distance to the nearest hospital—we also included a measure of patient satisfaction with primary physician services in the municipality. Data on patient satisfaction was obtained from an extensive questionnaire survey of 63,798 respondents. We found a statistically significant negative relationship between patient satisfaction and the number of hospital admissions. This conclusion was robust with regard to the empirical specification, and the effect was large.

Financial incentives and the supply of laboratory tests.

This study examined how the number of laboratory tests taken by a sample of Norwegian contract physicians is influenced by their private economy outside of the practice and by changes in remuneration. The data are drawn from 40,000 consultations carried out by 44 contract physicians in 1991–1994. Two factors which led to changes in the level of physicians’ income are considered: changes in remuneration for consultations and laboratory tests and changes in interest rates on loans and bank deposits. The effect which changes in interest rates have on physicians’ disposable income was calculated using information about their financial assets and debts obtained from tax assessments. The main finding was that changes in private economy and changes in remuneration have no or only a small effect on the number of laboratory tests taken. Our results suggest that fee regulation can be an effective means of controlling physicians’ income and therefore government expenditure on primary physician services.