Ivar Sønbø Kristiansen

Impact of payment method on behaviour of primary care physicians: a systematic review

Objective: To review the impact of payment systems on the behaviour of primary care physicians. Methods: All randomised trials, controlled before and after studies, and interrupted time series studies that compared capitation, salary, fee-for-service or target payments (mixed or separately) that were identified by computerised searches of the literature. Methodological quality assessment and data extraction were undertaken independently by two reviewers using a data checklist. Study results were qualitatively analysed. Results: Six studies met the inclusion criteria. There was considerable variation in the quality of reporting, study setting and the range of outcomes measured. Fee-for-service resulted in a higher quantity of primary care services provided compared with capitation but the evidence of the impact on the quantity of secondary care services was mixed. Fee-for-service resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but lower patient satisfaction with access to a physician compared with salary payment. The evidence of the impact of target payment on immunisation rates was inconclusive. Conclusions: There is some evidence to suggest that how a primary care physician is paid does affect his/her behaviour but the generalisability of these studies is unknown. Most policy changes in the area of payment systems are inadequately informed by research. Future changes to doctor payment systems need to be rigorously evaluated.

Epidemiology of hip fractures in Oslo, Norway

The incidence of hip fractures in Oslo has shown a secular increase during the past decades. The main aims of the present study were to report the current incidence of hip fractures in Oslo and to determine whether there is a seasonal variation in the occurrence of fractures. Using the electronic diagnosis registers and the lists of the operating theater for the hospitals in Oslo with somatic care, all patients with ICD-9 code 820.X (hip fracture) from May 1, 1996 to April 30, 1997 were identified. Medical records for all identified patients were obtained and diagnosis was verified. Using the population of Oslo on January 1, 1997 as the population at risk, the age- and gender-specific annual incidence rates were calculated. These rates were compared with those for 1988/89 and 1978/79. Outdoor temperature data for Oslo were obtained to study the relation between temperature and number of hip fractures. A total number of 1316 hip fractures was included, of which 78% occurred in women. An exponential increase in incidence with age was observed in both genders. The age-adjusted fracture rates per 10,000 for the age group > or =50 years were 118.0 and 44.0 in 1996/97, 124.3 and 44.9 in 1988/89, and 104.5 and 35.8 in 1978/79 for women and men, respectively. There was no significant seasonal variation in the incidence of hip fractures and no correlation between mean outdoor temperature and number of fractures for each month in 1996/97. The data show that the incidence of hip fractures in Oslo has not changed significantly during the last decade, and it is still the highest reported. The cold climate of Oslo does not seem to contribute to the high incidence.

Cost effectiveness of incremental programmes for lowering serum cholesterol concentration: is individual intervention worth while?

OBJECTIVE--To evaluate the relative cost effectiveness of various cholesterol lowering programmes. DESIGN--Retrospective analysis. SETTING--Norwegian cholesterol lowering programme in Norwegian male population aged 40-49 (n = 200,000), whose interventions comprise a population based promotion of healthier eating habits, dietary treatment (subjects with serum cholesterol concentration 6.0-7.9 mmol/l), and dietary and drug treatment combined (serum cholesterol concentration greater than or equal to 8.0 mmol/l). MAIN OUTCOME MEASURE--Marginal cost effectiveness ratios--that is, the ratio of net treatment costs (cost of treatment minus savings in treatment costs for coronary heart disease) to life years gained and to quality of life years (QALYs) saved. RESULTS--The cost per life year gained over 20 years of a population based strategy was projected to be 12 pounds. For an individual strategy based on dietary treatment the cost was about 12,400 pounds per life year gained and 111,600 pounds if drugs were added for 50% of the subjects with serum cholesterol concentrations greater than or equal to 8.0 mmol/l. CONCLUSIONS--The results underline the importance of marginal cost effectiveness analyses for incremental programmes of health care. The calculations of QALYs, though speculative, indicate that individual intervention should be implemented cautiously and within more selected groups than currently recommended. Drugs should be reserved for subjects with genetic hypercholesterolaemia or who are otherwise at very high risk of arteriosclerotic disease.

Number needed to treat: easily understood and intuitively meaningful? Theoretical considerations and a randomized trial

Graphic representation was used to explore to what extent the number needed to treat (NNT) conveys the appropriate notion of benefit for the individual patient in interventions aimed at delaying adverse events. A sample of the Danish population (n = 675) was interviewed face to face, and asked whether they would consent to a hypothetical drug that reduces the risk of heart attack. The benefit of the drug was expressed in terms of NNT and was randomly set at 10, 25, 50, 100, 200, and 400. NNT does not convey information on the proportion of patients being helped by an intervention or the size of the delay of the adverse event intended to be prevented. The proportion of people consenting to the hypothetical drug was about 80%, irrespective of NNT, and some of those who rejected the drug misinterpreted the meaning of NNT. Lay people may have difficulties in understanding the meaning of NNT, and clinicians may do well to use the NNT with caution until more is known about how patients comprehend it.

More postoperative femoral fractures with the Gamma nail than the sliding screw plate in the treatment of trochanteric fractures

Despite several studies showing a higher incidence of peri-implant femoral fractures with the Gamma nail than with a sliding screw plate (SSP), the Gamma nail has remained the standard implant for trochanteric fractures in many hospitals. We recorded 921 trochanteric fractures in the city of Oslo during 2 years and compared the reoperation frequency in patients treated with the Gamma nail (n 379) and SSP (n 542). The distribution of age and gender in the two treatment groups was the same. 65 patients were reoperated on, several of them more than once. The only significant difference between the two surgical methods in complications leading to a reoperation was the frequency of femoral shaft fractures. 17 of the patients treated with the Gamma nail had a new femoral fracture postoperatively, compared to 3 of those with a SSP. The relative risk of another femoral fracture after surgery was 12 (95% CI: 2.7-52) if the surgical device was a Gamma nail compared to a SSP.The Gamma nail therefore can not be recommended as the standard implant for trochanteric fractures.

Prevention of HPV-related cancers in Norway: cost-effectiveness of expanding the HPV vaccination program to include pre-adolescent boys.

Background Increasingly, countries have introduced female vaccination against human papillomavirus (HPV), causally linked to several cancers and genital warts, but few have recommended vaccination of boys. Declining vaccine prices and strong evidence of vaccine impact on reducing HPV-related conditions in both women and men prompt countries to reevaluate whether HPV vaccination of boys is warranted. Methods A previously-published dynamic model of HPV transmission was empirically calibrated to Norway. Reductions in the incidence of HPV, including both direct and indirect benefits, were applied to a natural history model of cervical cancer, and to incidence-based models for other non-cervical HPV-related diseases. We calculated the health outcomes and costs of the different HPV-related conditions under a gender-neutral vaccination program compared to a female-only program. Results Vaccine price had a decisive impact on results. For example, assuming 71% coverage, high vaccine efficacy and a reasonable vaccine tender price of

Radiology services for remote communities: cost minimisation study of telemedicine.

75 per dose, we found vaccinating both girls and boys fell below a commonly cited cost-effectiveness threshold in Norway (

Societal views on orphan drugs: cross sectional survey of Norwegians aged 40 to 67

83,000/quality-adjusted life year (QALY) gained) when including vaccine benefit for all HPV-related diseases. However, at the current market price, including boys would not be considered ‘good value for money.’ For settings with a lower cost-effectiveness threshold (

Why do some pregnant women prefer cesarean? The influence of parity, delivery experiences, and fear

30,000/QALY), it would not be considered cost-effective to expand the current program to include boys, unless the vaccine price was less than

Identification of cutpoints for acceptable health status and important improvement in patient-reported outcomes, in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.

36/dose. Increasing vaccination coverage to 90% among girls was more effective and less costly than the benefits achieved by vaccinating both genders with 71% coverage. Conclusions At the anticipated tender price, expanding the HPV vaccination program to boys may be cost-effective and may warrant a change in the current female-only vaccination policy in Norway. However, increasing coverage in girls is uniformly more effective and cost-effective than expanding vaccination coverage to boys and should be considered a priority.