Jon Magnussen

Early Supported Discharge for Stroke Patients Improves Clinical Outcome. Does It Also Reduce Use of Health Services and Costs

Background: An early supported discharge service (ESD) appears to be a promising alternative to conventional care. The aim of this trial was to compare the use of health services and costs with traditional stroke care during a one-year follow-up. Methods: Three hundred and twenty patients were randomly allocated either to ordinary stroke unit care or stroke unit care combined with ESD which was coordinated by a mobile team. The use of all health services was recorded prospectively; its costs were measured as service costs and represent a combination of calculated average costs and tariffs. Hospital expenses were measured as costs per inpatient day and adjusted for the DRG. Results: There was a reduction in average number of inpatient days at 52 weeks in favour of the ESD group (p = 0.012), and a non-significant reduction in total mean service costs in the ESD group (EUR 18,937/EUR 21,824). ESD service seems to be most cost-effective for patients with a moderate stroke. Conclusion: Acute stroke unit care combined with an ESD programme may reduce the length of institutional stay without increasing the costs of outpatient rehabilitation compared with traditional stroke care.

Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up

Objective To investigate associations between deep abdominal muscle activation and long-term pain outcome in chronic non-specific low back pain (LBP). Methods Recruitment of transversus abdominis and obliquus internus abdominis during the abdominal drawing-in manoeuvre was recorded by B-mode ultrasound and anticipatory onset of deep abdominal muscle activity with M-mode ultrasound. Recordings were done before and after 8 weeks with guided exercises for 109 patients with chronic non-specific LBP. Pain was assessed with a numeric rating scale (0–10) before and 1 year after intervention. Associations between muscle activation and long-term pain were examined by multiple linear and logistic regression methods. Results Participants with a combination of low baseline lateral slide in transversus abdominis and increased slide after intervention had better odds for long-term clinically important pain reduction (≥2 points on the numeric rating scale) compared with participants with small baseline slide and no improvement in slide (OR 14.70, 95% CI 2.41 to 89.56). There were no associations between contraction thickness ratios in transversus abdominis or obliquus internus abdominis and pain at 1-year follow-up. Transversus abdominis lateral slide before intervention was marginally associated with a lower OR for clinically important improvement in pain at 1-year follow-up (OR 0.76, 95% CI 0.62 to 0.93). Delayed onset of the abdominal muscles after the intervention period was weakly associated with higher long-term pain. Conclusion Improved transversus abdominis lateral slide among participants with low baseline slide was associated with clinically important long-term pain reduction. High baseline slide and delayed onset of abdominal muscles after the intervention period were weakly associated with higher pain at 1-year follow-up. Clinical Trial Registration number The study was preregistered in ClinicalTrials.gov with identifier NCT00201513.

DRGs: The road to hospital efficiency

In this paper, the effects of using diagnosis-related groups (DRGs) as the basis of a hospital funding mechanism and within a global budgeting mechanism are reviewed. Most forthcoming is the indeterminate effect of DRGs as a funding mechanism. By controlling only the price of hospital care, such systems remain vulnerable to compensatory increases in patient throughout, cost shifting and patient-shifting. Whether the use of DRGs has substantially reduced hospital cost per case is also not clear cut. Effects on patient outcome have not been adequately assessed. At this stage, use of DRGs within a system of global budgeting will simply focus attention on the current average costs of treating cases without consideration of whether such average costs represent efficient clinical practice. Efficient clinical practice is better established through use of less sophisticated techniques, such as clinical budgeting and cost-effectiveness analysis. The failure of more global budgeting in the past has been that patient outcome has not been monitored. Data on outcome are crucial to determining efficiency. Once efficient clinical practice is established through budgeting, DRGs could be calculated according to efficiency criteria rather than current average cost.

Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture. The protocol of the Trondheim Hip Fracture Trial

BackgroundHip fractures in older people are associated with high morbidity, mortality, disability and reduction in quality of life. Traditionally people with hip fracture are cared for in orthopaedic departments without additional geriatric assessment. However, studies of postoperative rehabilitation indicate improved efficiency of multidisciplinary geriatric rehabilitation as compared to traditional care. This randomized controlled trial (RCT) aims to investigate whether an additional comprehensive geriatric assessment of hip fracture patients in a special orthogeriatric unit during the acute in-hospital phase may improve outcomes as compared to treatment as usual in an orthopaedic unit.Methods/designThe intervention of interest, a comprehensive geriatric assessment is compared with traditional care in an orthopaedic ward. The study includes 401 home-dwelling older persons >70 years of age, previously able to walk 10 meters and now treated for hip fracture at St. Olav Hospital, Trondheim, Norway. The participants are enrolled and randomised during the stay in the Emergency Department. Primary outcome measure is mobility measured by the Short Physical Performance Battery (SPPB) at 4 months after surgery. Secondary outcomes measured at 1, 4 and 12 months postoperatively are place of residence, activities of daily living, balance and gait, falls and fear of falling, quality of life and depressive symptoms, as well as use of health care resources and survival.DiscussionWe believe that the design of the study, the randomisation procedure and outcome measurements will be of sufficient strength and quality to evaluate the impact of comprehensive geriatric assessment on mobility and other relevant outcomes in hip fracture patients.Trials registrationClinicalTrials.gov, NCT00667914

Measuring cost efficiency in the Nordic Hospitals—a cross-sectional comparison of public hospitals in 2002

The aim of this study was to compare the performance of hospital care in four Nordic countries: Norway, Finland, Sweden and Denmark. Using national discharge registries and cost data from hospitals, cost efficiency in the production of somatic hospital care was calculated for public hospitals. Data were collected using harmonised definitions of inputs and outputs for 184 hospitals and data envelopment analysis was used to calculate Farrell efficiency estimates for the year 2002. Results suggest that there were marked differences in the average hospital efficiency between Nordic countries. In 2002, average efficiency was markedly higher in Finland compared to Norway and Sweden. This study found differences in cost efficiency that cannot be explained by input prices or differences in coding practices. More analysis is needed to reveal the causes of large efficiency disparities between Nordic hospitals.

A randomised controlled study of the long-term effects of exercise training on mortality in elderly people: study protocol for the Generation 100 study

Introduction Epidemiological studies suggest that exercise has a tremendous preventative effect on morbidity and premature death, but these findings need to be confirmed by randomised trials. Generation 100 is a randomised, controlled study where the primary aim is to evaluate the effects of 5 years of exercise training on mortality in an elderly population. Methods and analysis All men and women born in the years 1936–1942 (n=6966), who were residents of Trondheim, Norway, were invited to participate. Between August 2012 and June 2013, a total of 1567 individuals (790 women) were included and randomised to either 5 years of two weekly sessions of high-intensity training (10 min warm-up followed by 4×4 min intervals at ∼90% of peak heart rate) or, moderate-intensity training (50 min of continuous work at ∼70% of peak heart rate), or to a control group that followed physical activity advice according to national recommendations. Clinical examinations, physical tests and questionnaires will be administered to all participants at baseline, and after 1, 3 and 5 years. Participants will also be followed up by linking to health registries until year 2035. Ethics and dissemination The study has been conducted according to the SPIRIT statement. All participants signed a written consent form, and the study has been approved by the Regional Committee for Medical Research Ethics, Norway. Projects such as this are warranted in the literature, and we expect that data from this study will result in numerous papers published in world-leading clinical journals; we will also present the results at international and national conferences. Trial registration number Clinical trial gov NCT01666340.

Case-based hospital financing: the case of Norway

Several European countries are experimenting with new ways of organising and financing the hospital sector. This paper discusses the present Norwegian reform, where a system of fixed grants is replaced by a combination of payment per case and fixed grants. Initially implemented in four hospitals only, the decision to move to a full-scale reform will be based on the evaluation of this pilot project. The paper presents two alternative hypotheses on how a system with case-based financing will influence the performance of hospitals. Given that hospitals adjust passively to the constraints imposed by the financing system, increased efficiency is to be expected. If hospitals and hospital owners (i.e. the counties) interact in a game dominated by the hospital, however, the efficiency of the hospital will not be influenced by the financing system. We argue that the design of the pilot project limits the possibility of discriminating between these two hypotheses. Nevertheless, a comparison of key variables in the pilot hospitals with a set of reference hospitals indicates that the change of financing system has not had any substantial effect on hospital efficiency. Thus we are inclined to believe that hospitals in fact are able to set the level of efficiency independent of whether they are financed by fixed grants or a payment per case.

Cost efficiency of university hospitals in the Nordic countries: a cross-country analysis

This paper estimates cost efficiency scores using the bootstrap bias-corrected procedure, including variables for teaching and research, for the performance of university hospitals in the Nordic countries. Previous research has shown that hospital provision of research and education interferes with patient care routines and inflates the costs of health care services, turning university hospitals into outliers in comparative productivity and efficiency analyses. The organisation of patient care, medical education and clinical research as well as available data at the university hospital level are highly similar in the Nordic countries, creating a data set of comparable decision-making units suitable for a cross-country cost efficiency analysis. The results demonstrate significant differences in university hospital cost efficiency when variables for teaching and research are entered into the analysis, both between and within the Nordic countries. The results of a second-stage analysis show that the most important explanatory variables are geographical location of the hospital and the share of discharges with a high case weight. However, a substantial amount of the variation in cost efficiency at the university hospital level remains unexplained.

Productivity growth in outpatient child and adolescent mental health services: the impact of case-mix adjustment.

The performance of health service providers may be monitored by measuring productivity. However, the policy value of such measures may depend crucially on the accuracy of input and output measures. In particular, an important question is how to adjust adequately for case-mix in the production of health care. In this study, we assess productivity growth in Norwegian outpatient child and adolescent mental health service units (CAMHS) over a period characterized by governmental utilization of simple productivity indices, a substantial increase in capacity and a concurrent change in case-mix. We analyze the sensitivity of the productivity growth estimates using different specifications of output to adjust for case-mix differences. Case-mix adjustment is achieved by distributing patients into eight groups depending on reason for referral, age and gender, as well as correcting for the number of consultations. We utilize the nonparametric Data Envelopment Analysis (DEA) method to implicitly calculate weights that maximize each units efficiency. Malmquist indices of technical productivity growth are estimated and bootstrap procedures are performed to calculate confidence intervals and to test alternative specifications of outputs. The dataset consist of an unbalanced panel of 48-60 CAMHS in the period 1998-2006. The mean productivity growth estimate from a simple unadjusted patient model (one single output) is 35%; adjusting for case-mix (eight outputs) reduces the growth estimate to 15%. Adding consultations increases the estimate to 28%. The latter reflects an increase in number of consultations per patient. We find that the governmental productivity indices strongly tend to overestimate productivity growth. Case-mix adjustment is of major importance and governmental utilization of performance indicators necessitates careful considerations of output specifications.

A Long-Term Follow-Up Programme for Maintenance of Motor Function after Stroke: Protocol of the life after Stroke—The LAST Study

Background. There are no evidence-based strategies that have been shown to be superior in maintaining motor function for months to years after the stroke. The LAST study therefore intends to assess the effect of a long-term follow-up program for stroke patients compared to standard care on function, disability and health. Design. This is a prospective, multi-site randomised controlled trial, with blinded assessment 18 months after inclusion. A total of 390 patients will be recruited and randomised to a control group, receiving usual care, or to an intervention group 10 to 16 weeks after onset of stroke. Patients will be stratified according to stroke severity, age above 80, and recruitment site. The intervention group will receive monthly coaching on physical activity by a physiotherapist for 18 consecutive months after inclusion. Outcomes. The primary outcome is motor function (Motor Assessment Scale) 18 months after inclusion. Secondary outcomes are: dependency, balance, endurance, health-related quality of life, fatigue, anxiety and depression, cognitive function, burden on caregivers, and health costs. Adverse events and compliance to the intervention will be registered consecutively during follow-up.