Toralf Hasvold

Social support in a wired world: Use of online mental health forums in Norway

This study explored the use of the four major Norwegian mental-health-related online discussion forums; who participate, why, and what implications use may have. The objective was to provide a basis for proposing relevant research questions and issues for public policy attention. A total of 492 responses to a web-based questionnaire were received. The respondents, predominantly women (78%) in the age range 18-35 years, found forum participation useful for information, and social contact and support. A majority (75%) found it easier to discuss personal problems online than face-to-face, and almost half say they discuss problems online that they do not discuss face-to-face. A majority would not have participated had they not had the option of using a pseudonym. Respondents perceive discussion groups as a supplement rather than a replacement of traditional mental health services, reporting no change in the amount or type of service used. A clear majority want professionals to take an active role in these types of forum. Comments from respondents indicate that forums may have an empowering effect. We believe that online interaction can have unique benefits for people suffering from mental disorders. Professionals will need new knowledge and perceptions of their roles, and public authorities will have to decide their role in influencing the quality of services offered, and the social values conveyed, to those who seek help through the Internet.

The european primary care monitor: structure, process and outcome indicators

BackgroundScientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care.MethodsA systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems).ResultsThe developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care.ConclusionsA standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.

Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial

Objective To assess the efficacy of caudal epidural steroid or saline injection in chronic lumbar radiculopathy in the short (6 weeks), intermediate (12 weeks), and long term (52 weeks). Design Multicentre, blinded, randomised controlled trial. Setting Outpatient multidisciplinary back clinics of five Norwegian hospitals. Participants Between October 2005 and February 2009, 461 patients assessed for inclusion (presenting with lumbar radiculopathy >12 weeks). 328 patients excluded for cauda equina syndrome, severe paresis, severe pain, previous spinal injection or surgery, deformity, pregnancy, ongoing breast feeding, warfarin therapy, ongoing treatment with non-steroidal anti-inflammatory drugs, body mass index >30, poorly controlled psychiatric conditions with possible secondary gain, and severe comorbidity. Interventions Subcutaneous sham injections of 2 mL 0.9% saline, caudal epidural injections of 30 mL 0.9% saline, and caudal epidural injections of 40 mg triamcinolone acetonide in 29 mL 0.9% saline. Participants received two injections with a two week interval. Main outcome measures Primary: Oswestry disability index scores. Secondary: European quality of life measure, visual analogue scale scores for low back pain and for leg pain. Results Power calculations required the inclusion of 41 patients per group. We did not allocate 17 of 133 eligible patients because their symptoms improved before randomisation. All groups improved after the interventions, but we found no statistical or clinical differences between the groups over time. For the sham group (n=40), estimated change in the Oswestry disability index from the adjusted baseline value was −4.7 (95% confidence intervals −0.6 to −8.8) at 6 weeks, −11.4 (−6.3 to −14.5) at 12 weeks, and −14.3 (−10.0 to −18.7) at 52 weeks. For the epidural saline intervention group (n=39) compared with the sham group, differences in primary outcome were −0.5 (−6.3 to 5.4) at 6 weeks, 1.4 (−4.5 to 7.2) at 12 weeks, and −1.9 (−8.0 to 4.3) at 52 weeks; for the epidural steroid group (n=37), corresponding differences were −2.9 (−8.7 to 3.0), 4.0 (−1.9 to 9.9), and 1.9 (−4.2 to 8.0). Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. Conclusions Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy. Trial registration Current Controlled Trials ISRCTN No 12574253.

Propagation of program control: A tool for distributed disease surveillance

Abstract Purpose The purpose of the study was (1) to identify the requirements for syndromic, disease surveillance and epidemiology systems arising from events such as the SARS outbreak in March 2003, and the deliberate spread of Bacillus anthracis, or anthrax, in the US in 2001; and (2) to use these specifications as input to the construction of a system intended to meet these requirements. An important goal was to provide information about the diffusion of a communicable disease without being dependent on centralised storage of information about individual patients or revealing patient-identifiable information. Methods The method applied is rooted in the engineering paradigm involving phases of analysis, system specification, design, implementation, and testing. The requirements were established from earlier projects’ conclusions and analysis of disease outbreaks. The requirements were validated by a literature study of syndromic and disease surveillance systems. The system was tested on simulated EHR databases generated from microbiology laboratory data. Results A requirements list that a syndromic and disease surveillance system should meet, and an open source system, “The Snow Agent system”, has been developed. The Snow Agent system is a distributed system for monitoring the status of a populations health by distributing processes to, and extracting epidemiological data directly from, the electronic health records (EHR) system in a geographic area. Conclusions Syndromic and disease surveillance tools should be able to operate at all levels in the health systems and across national borders. Such systems should avoid transferring patient identifiable data, support two-way communications and be able to define and incorporate new and unknown diseases and syndrome definitions that should be reported by the system. The initial tests of the Snow Agent system shows that it will easily scale to national level in Norway.

Properties of a federated epidemiology query system

PURPOSE The purpose of the study was to establish knowledge about how online access to epidemiological data from general practitioners (GPs) electronic health record (EHR) system should be provided. Before such systems are developed and deployed a decision about the appropriate system architecture must be made. Such a decision should ideally be based on knowledge about the properties of different system architectures. This choice is important because the system architecture may affect the willingness of GPs to participate in providing epidemiological data from their EHR system. METHOD Verifying the performance and properties of an architectural approach by implementing and deploying a system on a trans-institutional level and performing evaluations studies is a very resource demanding method to establish a foundation for the decision of appropriate system architecture. Instead, we have tried to create this foundation by constructing a prototype system, establish knowledge about the properties of the system using experiments, and finally compare the properties of the federated approach to the properties of the centralised approach. By using this methodological approach we provide the best available knowledge, on this stage, for the appropriate system architecture to use for providing access to epidemiological data from the local population. RESULTS Our experimental results show that it is possible to improve the timeliness and the temporal and spatial resolution of epidemiological data, compared to traditional centralised disease surveillance systems. Up-to-date epidemiological data from the local population may be provided directly from the source EHR system within 4s. The responsiveness of the system is minimally affected (0.1s) as the number of participating data providers grows from 1 to 49 data providers. The comparison of the federated approach to the centralised approach indicates that federated approaches avoid the privacy issues involved, as intended; it offers better scalability when computing speed is compared, and it provides better specificity because more data about the patient may be used. CONCLUSION The conclusion from our study is that the federated approach to providing epidemiological data about the local population has many benefits over the traditional centralised approach. A federated approach to an epidemiology system may raise the GPs awareness of local disease outbreak because it is possible to share information about incidence rates of communicable diseases and use of laboratory requests in a geographical area that predates laboratory-based disease surveillance. The effects of the federated approach could be improved data quality in the EHR systems and improved representativeness of the epidemiological data for the areas covered by such systems.

High referral rates to secondary care by general practitioners in Norway are associated with GPs’ gender and specialist qualifications in family medicine, a study of 4350 consultations

BackgroundReferral rates of general practitioners (GPs) are an important determinant of secondary care utilization. The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The main objective of this study was to assess the GPs’ referral rate to secondary care in Norway, any associations between the referral decision and patient, GP, health care characteristics and who initiated the referring issue in the consultation.MethodsThe probabilities of referral to secondary care and/or radiological examination were examined in 100 consecutive consultations of 44 randomly chosen Norwegian GPs. The GPs recorded whether the issue of referral was introduced, who introduced it and if the patient was referred. Multilevel and naive multivariable logistic regression analyses were performed to explore associations between the probability of referral and patient, GP and health care characteristics.ResultsOf the 4350 consultations included, 13.7% (GP range 4.0%-28.0%) of patients were referred to secondary somatic and psychiatric care. Female GPs referred significantly more frequently than male GPs (16.0% versus 12.6%, adjusted odds ratio, AOR, 1.25), specialists in family medicine less frequently than their counterparts (12.5% versus 14.9%, AOR 0.76) and salaried GPs more frequently than private practitioners (16.2% versus 12.1%, AOR 1.36).In 4.2% (GP range 0%-12.9%) of the consultations, patients were referred to radiological examination. Specialists in family medicine, salaried GPs and GPs with a Norwegian medical degree referred significantly more frequently to radiological examination than their counterparts (AOR 1.93, 2.00 and 1.73, respectively).The issue of referral was introduced in 23% of the consultations, and in 70.6% of these cases by the GP. The high referrers introduced the referral issue significantly more frequently and also referred a significantly larger proportion when the issue was introduced.ConclusionsThe main finding of the present study was a high overall referral rate, and a striking range among the GPs. Male GPs and specialists in family medicine referred significantly less frequently to secondary care, but the latter referred more frequently to radiological examination. Our findings indicate that intervention on high referrers is a potential area for quality improvement, and there is a need to explore the referral decision process itself.

Does long-term care use within primary health care reduce hospital use among older people in Norway? A national five-year population-based observational study.

BackgroundPopulation ageing may threaten the sustainability of future health care systems. Strengthening primary health care, including long-term care, is one of several measures being taken to handle future health care needs and budgets. There is limited and inconsistent evidence on the effect of long-term care on hospital use. We explored the relationship between the total use of long-term care within public primary health care in Norway and the use of hospital beds when adjusting for various effect modifiers and confounders.MethodsThis national population-based observational study consists of all Norwegians (59% women) older than 66 years (N = 605676) (13.2% of total population) in 2002-2006. The unit of analysis was defined by municipality, age and sex. The association between total number of recipients of long-term care per 1000 inhabitants (LTC-rate) and hospital days per 1000 inhabitants (HD-rate) was analysed in a linear regression model. Modifying and confounding effects of socioeconomic, demographic and geographic variables were included in the final model. We defined a difference in hospitalization rates of more than 1000 days per 1000 inhabitants as clinically important.ResultsThirty-one percent of women and eighteen percent of men were long-term care users. Men had higher HD-rates than women. The crude association between LTC-rate and HD-rate was weakly negative. We identified two effect modifiers (age and sex) and two strong confounders (travel time to hospital and mortality). Age and sex stratification and adjustments for confounders revealed a positive statistically significant but not clinically important relationship between LTC-rates and hospitalization for women aged 67-79 years and all men. For women 80 years and over there was a weak but negative relationship which was neither statistically significant nor clinically important.ConclusionsWe found a weak positive adjusted association between LTC-rates and HD-rates. Opposite to common belief, we found that increased volume of LTC by itself did not reduce pressure on hospitals. There still is a need to study integrated care models for the elderly in the Norwegian setting and to explore further why municipalities far away from hospital achieve lower use of hospital beds.

Is a high level of general practitioner consultations associated with low outpatients specialist clinic use? A cross-sectional study

Objective To examine if increased general practice activity is associated with lower outpatient specialist clinic use. Design Cross-sectional population based study. Setting All 430 Norwegian municipalities in 2009. Participants All Norwegians aged ≥65 years (n=721 915; 56% women—15% of the total population). Main outcome measure Specialised care outpatient clinic consultations per 1000 inhabitants (OPC rate). Main explanatory: general practitioner (GP) consultations per 1000 inhabitants (GP rate). Results In total, there were 3 339 031 GP consultations (57% women) and 1 757 864 OPC consultations (53% women). The national mean GP rate was 4625.2 GP consultations per 1000 inhabitants (SD 1234.3) and the national mean OPC rate was 2434.3 per 1000 inhabitants (SD 695.3). Crude analysis showed a statistically significant positive association between GP rates and OPC rates. In regression analyses, we identified three effect modifiers; age, mortality and the municipal composite variable of ‘hospital status’ (present/not present) and ‘population size’ (small, medium and large). We stratified manually by these effect modifiers into five strata. Crude stratified analyses showed a statistically significant positive association for three out of five strata. For the same three strata, those in the highest GP consultation rate quintile had higher mean OPC rates compared with those in the lowest quintile after adjustment for confounders (p<0.001). People aged ≥85 in small municipalities had approximately 30% lower specialist care use compared with their peers in larger municipalities, although the association between GP-rates and OPC-rates was still positive. Conclusions In a universal health insurance system with high GP-accessibility, a health policy focusing solely on a higher activity in terms of GP consultations will not likely decrease OPC use among elderly.

Examination of final-year medical students in general practice.

With general practice recognized as one of three major subjects in the Tromsø medical school curriculum, a matching examination counterpart was needed. The aim was to develop and implement an examination in an authentic general practice setting for final-year medical students. In a general practice surgery, observed by two examiners and one fellow student, the student performs a consultation with a consenting patient who would otherwise have consulted his/her general practitioner (GP). An oral examination follows. It deals with the consultation process, the observed communication between “doctor” and patient, and with clinical problem-solving, taking todays patient as a starting point. The session is closed by discussion of a public-health-related question. Since 2004 the model has been evaluated through questionnaires to students, examiners, and patients, and through a series of review meetings among examiners and students. Examination in general practice using unselected, consenting patients mimics real life to a high degree. It constitutes one important element in a comprehensive assessment process. This is considered to be an acceptable and appropriate way of testing the students before graduation.