Jan Erik Askildsen

Prioritization and patients' rights: Analysing the effect of a reform in the Norwegian Hospital Sector

The right to equal treatment, irrespective of age, gender, ethnicity, socio-economic status and place of residence, is an important principle for several health care systems. A reform of the Norwegian hospital sector of 2002 may be used as a relevant experiment for investigating whether centralization of ownership and management structures will lead to more equal prioritization practices over geographical regions. One concern was variation in waiting times across the country. The reform was followed up in subsequent years by some other policy initiatives that also aimed at reducing waiting lists. We measure prioritization practice by a method that takes departure in recommended maximum waiting times from medical guidelines. We merge the information from the guidelines with individual patient data on actual waiting times for the period 1999-2005. This way we can monitor whether each patient in the available register of actual hospital visits has waited shorter or longer than what is considered medically acceptable by the guideline. The results indicate no equalization between the five new health regions, but we find evidence of more equal prioritization within four of the health regions. Our method of measuring prioritizations allows us to analyse how prioritization practice evolved over time after the reform, thus covering some further initiatives with the same objective. The results indicate that an observed reduction in waiting times after the reform have favoured patients of lower prioritization status, something we interpret as a general worsening of prioritization practices over time.

Monitoring prioritisation in the public health‐care sector by use of medical guidelines. The case of Norway

This paper presents a new way to monitor priority settings in public health-care systems. We take departure in medical guidelines prescribing acceptable waiting times for different medical descriptions. Allocating ICD10 codes to the medical descriptions, we are able to compare actual waiting times to the recommended maximum waiting times. This way we use the medical guidelines as a tool for monitoring prioritisation in the health sector. In an application, using data from the Norwegian Patient Register, we test statistically for compliance with the guidelines. The results indicate that patients suffering from the most severe conditions are receiving too low priority in the Norwegian health-care sector relative to patients of lower priority.

Excessive costs of COPD in ever-smokers. A longitudinal community study.

AIM We aimed to estimate the societal treatment-related costs of COPD in hospital- and population-based subjects with spirometry defined COPD, relative to a control group. METHODS 81 COPD cases and 132 controls without COPD were randomly recruited from a general population, as were 205 COPD patients from a hospital register. All participants were ever-smokers of at least 40 years of age, followed for 12 months. Data on comorbid conditions and spirometry were collected at baseline. Standardized telephone interviews every third month gave information on use of healthcare services and exacerbations of respiratory symptoms. RESULTS The increased (excessive) median annual costs per case having stage II, stage III and stage IV COPD were € (95% CI) 400 (105-695), 1918 (1268-2569) and 1870 (1031-2709), respectively, compared to the population-based controls. Costs increased with €81 (95% CI 50-112) per exacerbation of respiratory symptoms and €461 (95% CI 354-567) per comorbid condition. Excessive costs for hospital COPD patients were threefold that of the population-based COPD cases. CONCLUSION The excessive treatment-related cost of COPD stage II+ in ever-smokers of at least 40 years was estimated to €105 million for Norway. Comorbidity was a dominant predictor of excessive cost in COPD.

An economic model to evaluate cost-effectiveness of computer assisted knee replacement surgery in Norway

BackgroundThe use of Computer Assisted Surgery (CAS) for knee replacements is intended to improve the alignment of knee prostheses in order to reduce the number of revision operations. Is the cost effectiveness of computer assisted surgery influenced by patient volume and age?MethodsBy employing a Markov model, we analysed the cost effectiveness of computer assisted surgery versus conventional arthroplasty with respect to implant survival and operation volume in two theoretical Norwegian age cohorts. We obtained mortality and hospital cost data over a 20-year period from Norwegian registers. We presumed that the cost of an intervention would need to be below NOK 500,000 per QALY (Quality Adjusted Life Year) gained, to be considered cost effective.ResultsThe added cost of computer assisted surgery, provided this has no impact on implant survival, is NOK 1037 and NOK 1414 respectively for 60 and 75-year-olds per quality-adjusted life year at a volume of 25 prostheses per year, and NOK 128 and NOK 175 respectively at a volume of 250 prostheses per year. Sensitivity analyses showed that the 10-year implant survival in cohort 1 needs to rise from 89.8% to 90.6% at 25 prostheses per year, and from 89.8 to 89.9% at 250 prostheses per year for computer assisted surgery to be considered cost effective. In cohort 2, the required improvement is a rise from 95.1% to 95.4% at 25 prostheses per year, and from 95.10% to 95.14% at 250 prostheses per year.ConclusionsThe cost of using computer navigation for total knee replacements may be acceptable for 60-year-old as well as 75-year-old patients if the technique increases the implant survival rate just marginally, and the department has a high operation volume. A low volume department might not achieve cost-effectiveness unless computer navigation has a more significant impact on implant survival, thus may defer the investments until such data are available.

Cost-Effectiveness Analysis (CEA) of Intravenous Urography (IVU) and Unenhanced Multidetector Computed Tomography (MDCT) for Initial Investigation of Suspected Acute Ureterolithiasis

Background: It is important to compare the cost and effectiveness of multidetector computed tomography (MDCT) and intravenous urography (IVU) to determine the most cost-effective alternative for the initial investigation of acute ureterolithiasis. Purpose: To analyze the task-specific variable costs combined with the diagnostic effect of MDCT and IVU for patients with acute flank pain, and to determine which is most cost effective. Material and Methods: 119 patients with acute flank pain suggestive of stone disease (ureterolithiasis) were examined by both MDCT and IVU. Variable costs related to medical equipment, consumption material, equipment control, and personnel were calculated. The diagnostic effect was assessed. Results: The variable costs of MDCT versus IVU were EUR 32 and EUR 117, respectively. This significant difference was mainly due to savings in examination time, higher annual examination frequency, lower material costs, and no use of contrast media. As for diagnostic effect, MDCT proved considerably more accurate in the diagnosis of stone disease than IVU and markedly more accurate concerning differential diagnoses. Conclusion: MDCT had lower differential costs and a higher capacity to determine correctly stone disease and differential diagnoses, as compared to IVU, in patients with acute flank pain. Consequently, MDCT is a dominant alternative to IVU when evaluated exclusively from a cost-effective perspective.

How do Hospitals Respond to Price Changes? Evidence from Norway

Many publicly funded health systems use activity-based financing to increase hospital production and efficiency. The aim of this study is to investigate whether price changes for different treatments affect the number of patients treated and the mix of activity provided by hospitals. We exploit the variations in prices created by the changes in the national average treatment cost per diagnosis-related group (DRG) offered to Norwegian hospitals over a period of 5 years (2003-2007). We use the data from Norwegian Patient Register, containing individual-level information on age, gender, type of treatment, diagnosis, number of co-morbidities and the national average treatment costs per DRG. We employ fixed-effect models to examine the changes in the number of patients treated within the DRGs over time. The results suggest that a 10% increase in price leads to about 0.8-1.3% increase in the number of patients treated for DRGs, which are medical (for both emergency and elective patients). In contrast, we find no price effect for DRGs that are surgical (for both emergency and elective patients). Moreover, we find evidence of upcoding. A 10% increase in the ratio of prices between patients with and without complications increases the proportion of patients coded with complications by 0.3-0.4 percentage points.

Union membership and wage formation

Abstract This paper examines wage effects of different measures of trade union membership rates. A demographic model separates union members into three categories: employed, unemployed and inactive union members. The union membership data from the demographic model are merged with industry data. The empirical findings indicate a positive effect on wages from high union membership rates. Furthermore, membership, as measured by the number of active, employed and unemployed union members, constitutes the relevant measure of union membership when analysing wage formation. Including inactive members, such as retirees or using only employed workers, biases the estimated wage effects.

Productivity losses in chronic obstructive pulmonary disease: a population-based survey

Objectives We aimed to estimate incremental productivity losses (sick leave and disability) of spirometry-defined chronic obstructive pulmonary disease (COPD) in a population-based sample and in hospital-recruited patients with COPD. Furthermore, we examined predictors of productivity losses by multivariate analyses. Methods We performed four quarterly telephone interviews of 53 and 107 population-based patients with COPD and controls, as well as 102 hospital-recruited patients with COPD below retirement age. Information was gathered regarding annual productivity loss, exacerbations of respiratory symptoms and comorbidities. Incremental productivity losses were estimated by multivariate quantile median regression according to the human capital approach, adjusting for sex, age, smoking habits, education and lung function. Main effect variables were COPD/control status, number of comorbidities and exacerbations of respiratory symptoms. Results Altogether 55%, 87% and 31% of population-based COPD cases, controls and hospital patients, respectively, had a paid job at baseline. The annual incremental productivity losses were 5.8 (95% CI 1.4 to 10.1) and 330.6 (95% CI 327.8 to 333.3) days, comparing population-recruited and hospital-recruited patients with COPD to controls, respectively. There were significantly higher productivity losses associated with female sex and less education. Additional adjustments for comorbidities, exacerbations and FEV1% predicted explained all productivity losses in the population-based sample, as well as nearly 40% of the productivity losses in hospital-recruited patients. Conclusions Annual incremental productivity losses were more than 50 times higher in hospital-recruited patients with COPD than that of population-recruited patients with COPD. To ensure a precise estimation of societal burden, studies on patients with COPD should be population-based.

Aspects of healthcare utilisation in self-reported obstructive lung disease

Introduction:  Utilisation of healthcare resources because of pulmonary diseases have previously been presented according to lung function or symptom severity. We aimed to compare the associations of symptoms and lung function to healthcare and social service utilisation in subjects with self‐reported obstructive lung diseases (OLDs) (asthma, chronic obstructive pulmonary disease, chronic bronchitis, emphysema).

The impact of different prioritisation policies on waiting times: Case studies of Norway and Scotland

We investigate the distributional consequences of two different waiting times initiatives, one in Norway, and one in Scotland. The primary focus of Scotlands recent waiting time reforms, introduced in 2003, and modified in 2005 and 2007, has been on reducing maximum waiting times through the imposition of high profile national targets accompanied by increases in resources. In Norway, the focus of the reform introduced in September 2004, has been on assigning patients referred to hospital a maximum waiting time based on disease severity, the expected benefit and the cost-effectiveness of the treatment. We use large, national administrative datasets from before and after each of these reforms and assign priority groups based on the maximum waiting times stipulated in medical guidelines. The analysis shows that the lowest priority patients benefited most from both reforms. This was at the cost of longer waiting times for patients that should have been given higher priority in Norway, while Scotlands high priority patients remained unaffected.