Peder Andreas Halvorsen

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

Abstract Objectives: To determine the social costs of providing a rural population with radiology services under three different systems: the existing system (a small x ray unit at the remote site and all other examinations at the nearest radiology department (the host site)); a teleradiology system (most examinations at the remote site and more advanced examinations at the host site); and all examinations at the host site. Design: Cost minimisation study. Setting: Primary health care in a remote community in Norway. Subjects: A randomly selected sample (n=597) of all patients (n=1793) having radiological examinations in 1993. Main outcome measures: Annual direct medical costs, direct non-medical (travel) costs, and indirect costs (lost production) of the three options. Results: After exclusion of costs common to the three systems the direct medical, direct non-medical, and indirect costs of the three options were, respectively, £9000, £51 000, and £31 500 (total £91 500) for the existing system; £108 000, £2000, and £13 500 (total £123 500) for the teleradiology option; and £0, £75 000, and £42 000 (£117 000 in total) for the “all at host” option. Sensitivity analyses indicated that the existing system is the least costly option except when lost leisure is valued as highly as lost production. Conclusion: The teleradiology option did not seem to be cost saving in the study community. Such systems, however, may be justified on the grounds of equity of access and quality of care. Key messages Few, if any, studies of the cost effectiveness of this technology have been published This study indicates that in remote primary health care, teleradiology is not less costly than conventional technologies Teleradiology may be justified as a means to increase equity in access to high quality health care in remote communities The subject calls for further studies in other countries

Socio-economic inequalities in health care utilisation in Norway: a population based cross-sectional survey

BackgroundNorway provides universal health care coverage to all residents, but socio-economic inequalities in health are among the largest in Europe. Evidence on inequalities in health care utilisation is sparse, and the aim of this population based study was to investigate socio-economic inequalities in the utilisation of health care services in Tromsø, Norway.MethodsWe used questionnaire data from the cross-sectional Tromsø Study, conducted in 2007–8. All together 12,982 persons aged 30–87 years participated with the response rate of 65.7%. This is slightly more than one third of the total population (33.8%) in the mentioned age group in Tromsø municipality. By logistic regression analyses we studied associations between household income, education and self-rated occupational status and the utilisation of general practitioner, somatic and psychiatric specialist outpatient services. The outcome variables were probability and frequency of use during the previous 12 months. Analyses were stratified by gender and adjusted for age, marital status, and self-rated health.ResultsSelf-rated health was the dominant predictor of health care utilisation. Women’s probability of visiting a general practitioner did not vary by socio-economic status, but high income was associated with less frequent use (odds ratio [OR] for trend 0.89, 95% confidence interval [CI] 0.81-0.98). In men, high income predicted lower probability and frequency of general practitioner utilisation (OR for trend 0.85, CI 0.76-0.94, and 0.86, 0.78-0.95, respectively). Women’s probability of visiting a somatic specialist increased with higher income (OR for trend 1.11, CI 1.01-1.21) and higher education (OR for trend 1.27, CI 1.16-1.39). We found the same trends for men, though significant only for education (OR for trend 1.14, CI 1.05-1.25). The likelihood of visiting psychiatric specialist services increased with higher education and decreased with higher income in women (OR for trend 1.57, CI 1.24-1.98, and 0.69, 0.56-0.86, respectively), but did not vary significantly by socio-economic variables in men. Higher income predicted more frequent use of psychiatric specialist services in men (OR for trend 2.02, CI 1.12-3.63).ConclusionsThis study revealed important inequalities in the utilisation of health care services in Norway, inequalities which may contribute to sustaining inequalities in health outcomes.

Continuity of GP care is related to reduced specialist healthcare use: a cross-sectional survey.

BACKGROUND Continuity of GP care is associated with reduced hospitalisations, but solid documentation of its relationship to use of outpatient specialist services is lacking. AIM To test the association between continuity of GP care and use of inpatient and outpatient specialist services. DESIGN AND SETTING A cross-sectional population-based study with questionnaire data from the sixth Tromsø Study (2007-2008). METHOD Descriptive statistics and two sample t-test were used to estimate specialist healthcare use according to duration of the GP-patient relationship. Logistic regression analysis was used to assess associations between duration and intensity of the GP-patient relationship and use of specialist care. Analyses were adjusted for sex, age, marital status, income, education, and self-rated health, and also stratified by self-rated health and age. RESULTS Of 10,624 eligible GP users, 85% had seen the same GP for >2 years. The probability of visiting outpatient specialist services was significantly lower among these participants compared to those with a shorter GP relationship (odds ratio [OR] = 0.81, 95% confidence interval [95% CI] = 0.71 to 0.92). Similar findings were found for hospitalisations (OR = 0.76, 95% CI = 0.64 to 0.90). Stratified analyses revealed that these associations were not dependent on self-rated health or age. The probability of specialist use increased for the frequent GP users. CONCLUSION Continuity of GP care is associated with reduced use of outpatient specialist services and hospitalisations. Healthcare providers and policymakers who wish to limit use of specialist health care may do well to perform and organise health services in ways that support continuity in general practice.

What professional activities do general practitioners find most meaningful? Cross sectional survey of Norwegian general practitioners.

BackgroundHealth reforms in many countries affect the scope and nature of primary care. General Practitioners (GPs) are expected to spend more time developing public health, preventive health care, coordination of care and teamwork. We aimed to explore which professional activities GPs consider to be meaningful and how they would like to prioritise tasks.MethodsIn a cross sectional online survey 3,270 GPs were invited to consider twenty different activities in general practice. They were asked to rate each of them on a Likert scale anchored from 1 (not meaningful) to 5 (very meaningful). They then selected three activities from the item list on which they would like to spend more time and three activities on which they would like to spend less time. We used multinomial logistic regression to explore associations between the GPs’ preferences for time spent on preventive health care activities and age, gender and practice characteristics.ResultsApproximately 40% (n=1,308) responded. The most meaningful activities were handling common symptoms and complaints (94% scored 4 or 5), chronic somatic diseases (93%), terminal care (80%), chronic psychiatric diseases (77%), risk conditions (76%) and on call emergency services (70%). In terms of priority the same items prevailed except that GPs would like to spend less time on emergency services. Items with low priority were health certificates, practice administration, meetings with local health authorities, medically unexplained symptoms, addiction medicine, follow up of people certified unfit for work, psychosocial problems, preventive health clinics for children and school health services. In multivariate regression models physician and practice characteristics explained no more than 10% of the variability in the GPs’ preferences for time spent on preventive health care services.ConclusionsThe GPs found diagnosis and treatment of diseases most meaningful. Their priorities were partly at odds with those of the health authorities and policy makers.

Associations between patients’ risk attitude and their adherence to statin treatment – a population based questionnaire and register study

BackgroundPoor adherence to medical treatment may have considerable consequences for the patients’ health and for healthcare costs to society. The need to understand the determinants for poor adherence has motivated several studies on socio-demographics and comorbidity. Few studies focus on the association between risk attitude and adherence. The aim of the present study was to estimate associations between patients’ adherence to statin treatment and different dimensions of risk attitude, and to identify subgroups of patients with poor adherence.MethodsPopulation-based questionnaire and register-based study on a sample of 6393 persons of the general. Danish population aged 20–79. Data on risk attitude were based on 4 items uncovering health-related as well as financial dimensions of risk attitude. They were collected through a web-based questionnaire and combined with register data on redeemed statin prescriptions, sociodemographics and comorbidity. Adherence was estimated by proportion of days covered using a cut-off point at 80 %.ResultsFor the dimension of health-related risk attitude, “Preference for GP visit when having symptoms”, risk-neutral and risk-seeking patients had poorer adherence than the risk-averse patients, OR 0.80 (95 %-CI 0.68–0.95) and OR 0.83 (95 %-CI 0.71–0.98), respectively. No significant association was found between adherence and financial risk attitude. Further, patients in the youngest age group and patients with no CVD were less adherent to statin treatment.ConclusionWe find some indication that risk attitude is associated with adherence to statin treatment, and that risk-neutral and risk-seeking patients may have poorer adherence than risk-averse patients. This is important for clinicians to consider when discussing optimal treatment decisions with their patients. The identified subgroups with the poorest adherence may deserve special attention from their GP regarding statin treatment.

General practitioners’ altered preferences for private practice vs. salaried positions: a consequence of proposed policy regulations?

BackgroundGeneral practitioners (GPs) in most high-income countries have a history of being independent private providers with much autonomy. While GPs remain private providers, their autonomous position appears to be challenged by increased policy regulations. This paper examines the extent to which GPs’ preferences for private practice vs. salaried contracts changed in a period where a new health care reform, involving proposed increased regulations of the GPs, was introduced.MethodsWe use data collected from Norwegian GPs through structured online questionnaires in December 2009 and May 2012.ResultsWe find that the proportion of GPs who prefer private practice (i.e. the default contract for GPs in Norway) decreases from 52% to 36% in the period from 2009 to 2012. While 67% of the GPs who worked in private practice preferred this type of contract in 2009, the proportion had dropped by 20 percentage points in 2012. Salaried contracts are preferred by GPs who are young, work in a small municipality, have more patients listed than they prefer, work more hours per week than they prefer, have relatively low income or few patients listed.ConclusionWe find that GPs’ preferences for private practice vs. salaried positions have changed substantially in the last few years, with a significant shift towards salaried contracts. With the proportions of GPs remaining fairly similar across private practice and salaried positions, there is an increasing discrepancy between GPs’ current contract and their preferred one.

Joint and Separate Evaluation of Risk Reduction: Impact on Sensitivity to Risk Reduction Magnitude in the Context of 4 Different Risk Information Formats

Background. When people make choices, they may have multiple options presented simultaneously or, alternatively, have options presented 1 at a time. It has been shown that if decision makers have little experience with or difficulties in understanding certain attributes, these attributes will have greater impact in joint evaluations than in separate evaluations. The authors investigated the impact of separate versus joint evaluations in a health care context in which laypeople were presented with the possibility of participating in risk-reducing drug therapies. Methods. In a randomized study comprising 895 subjects aged 40 to 59 y in Odense, Denmark, subjects were randomized to receive information in terms of absolute risk reduction (ARR), relative risk reduction (RRR), number needed to treat (NNT), or prolongation of life (POL), all with respect to heart attack, and they were asked whether they would be willing to receive a specified treatment. Respondents were randomly allocated to valuing the interventions separately (either great effect or small effect) or jointly (small effect and large effect). Results. Joint evaluation reduced the propensity to accept the intervention that offered the smallest effect. Respondents were more sensitive to scale when faced with a joint evaluation for information formats ARR, RRR, and POL but not for NNT. Evaluability bias appeared to be most pronounced for POL and ARR. Conclusion. Risk information appears to be prone to evaluability bias. This suggests that numeric information on health gains is difficult to evaluate in isolation. Consequently, such information may bear too little weight in separate evaluations of risk-reducing interventions.

What information do patients need to make a medical decision

As a decision scientist and primary care physician, I often find myself living in different worlds when considering this question. According to expected utility theory, the answer is simple: given different options, one needs to know probabilities of possible outcomes and assess the value (utility) of each of these outcomes. The rest, such as modeling and calculation, is usually not so simple. Therefore, I guess that busy clinicians would readily give up the idea that the majority of medical decisions could be based on proper decision analyses. Alternatively, we could aim for shared or informed decision making, but the standard it sets for highquality decisions is still hard to meet in clinical practice. This supplement to Medical Decision Making presents results from the DECISIONS study, a large sample telephone interview survey of the US population. The authors studied prevalence, patient knowledge, and patient-provider interactions for actual decisions pertaining to cancer screening, common medication treatment, and elective surgical procedures. Although limited by the respondents’ ability to recall their clinical encounters, these data provide valuable insights into everyday clinical decisions. An expansion of our knowledge base in this direction is most welcome. Among the findings of the DECISIONS study is an intriguing inconsistency: respondents indicated that they felt well informed about the medical intervention in question but failed to answer knowledge questions about the intervention correctly. The authors seem to take the stance that passing the knowledge tests is what counts for a patient to be seen as well informed. They raise concerns that standards of informed decision making were not met and hence that quality improvement is needed. Their concerns are probably justified; feeling well informed may sometimes reflect overconfidence, one of the classic biases in judgment and decision making. Before we jump to that conclusion, however, it is worthwhile to consider an alternative hypothesis: when people say they feel well informed, there might be good reasons. For example, one might wonder whether this finding reflects specific qualities of patient-provider interactions beyond conveying factual knowledge. Some studies suggest that patients want clinicians to share not only the facts but also their honest opinion about the best course of action. This could perhaps be formulated as a decision rule or heuristic: ‘‘When faced with a difficult decision, seek the advice of a competent and trusted other.’’ This is not to say that facts are unimportant to patients. For example, there is evidence to suggest that patients want numeric facts and that they think effect size is important when considering treatment options. Furthermore, including numeric statements in risk communication may increase the patient’s trust and belief in risk information. However, it is not clear exactly how patients wish to use such information. Edwards and Elwyn make a distinction between involvement in the decision-making process and decisional responsibility. Their concept of shared decision making may include both; the core idea is to involve patients in decision making to the extent that they desire. Perhaps the respondents of the DECISIONS study felt well informed due to appropriate involvement (to the desired extent) rather than inflated confidence in their factual knowledge. Some of the knowledge questions included in the DECISIONS survey asked the respondents for numbers such as normal values and frequencies. There From the Department of Community Medicine, University of Tromsø, Norway.

The ecology of medical care in Norway: wide use of general practitioners may not necessarily keep patients out of hospitals

Background Our aim was to investigate the pattern of self reported symptoms and utilisation of health care services in Norway. Design and Methods With data from the cross-sectional Tromsø Study (2007-8), we estimated population proportions reporting symptoms and use of seven different health services. By logistic regression we estimated differences according to age and gender. Results In this study 12,982 persons aged 30-87 years participated, constituting 65.7% of those invited. More than 900/1000 reported symptoms or health problems in a year as well as in a month, and 214/1000 and 816/1000 visited a general practitioner once or more in a month and a year, respectively. The corresponding figures were 91/1000 and 421/1000 for specialist outpatient visits, and 14/1000 and 116/1000 for hospitalisations. Physiotherapists were visited by 210/1000, chiropractors by 76/1000, complementary and alternative medical providers by 127/1000, and dentists by 692/1000 in a year. Women used most health care services more than men, but genders used hospitalisations and chiropractors equally. Utilisation of all services increased with age, except chiropractors, dentists and complementary and alternative medical providers. Conclusions Almost the entire population reported health related problems during the previous year, and most residents visited a general practitioner. Yet there were high rates of inpatient and outpatient specialist utilisation. We suggest that wide use of general practitioners may not necessarily keep patients out of specialist care and hospitals. Acknowledgments the authors would like to thank Tor Anvik for a significant contribution in developing the idea for the study, Tom Wilsgård for useful discussions about the statistical analyses and Jarl-Stian Olsen for graphic design of the figures. They would also thank the people of Tromsø and The Tromsø Study for giving data to this study. Northern Norway Regional Health Authority and The University of Tromsø funded this research.

Rural GPs’ attitudes toward participating in emergency medicine: a qualitative study

Abstract Objective: Health authorities want to increase general practitioner (GP) participation in emergency medicine, but the role of the GP in this context controversial. We explored GPs’ attitudes toward emergency medicine and call outs. Design: Thematic analysis of focus group interviews. Setting: Four rural casualty clinics in Norway. Participants: GPs with experience ranging from one to 32 years. Results: The GPs felt that their role had changed from being the only provider of emergency care to being one of many. In particular, the emergency medical technician teams (EMT) have evolved and often manage well without a physician. Consequently, the GPs get less experience and feel more uncertain when encountering emergencies. Nevertheless, the GPs want to participate in call outs. They believed that their presence contributes to better patient care, and the community appreciates it. Taking part in call outs is seen as being vital to maintaining skills. The GPs had difficulties explaining how to decide whether to participate in call outs. Decisions were perceived as difficult due to insufficient information. The GPs assessed factors, such as distance from the patient and crowding at the casualty clinic, differently when discussing participation in call outs. Conclusion: Although their role may have changed, GPs argue that they still play a part in emergency medicine. The GPs claim that by participating in call outs, they maintain their skills and improve patient care, but further research is needed to help policy makers and clinicians decide when the presence of a GP really counts. Norwegian health authorities want to increase participation by general practitioners (GPs) in emergency medicine, but the role of the GP in this context is controversial. KEY POINTS The role of the GP has changed, but GPs argue that they still play an important role in emergency medicine. GPs believe that their presence on call outs improve patient care, but they find it defensible that patients are tended to by emergency medical technicians (EMTs) only. GPs offered different assessments regarding whether to participate in call outs in seemingly similar cases.