Exploring variation in timely reperfusion treatment in ST-segment elevation myocardial infarction in Norway: a national register-based cohort study.

OBJECTIVES: This study aimed to investigate determinants of reperfusion within recommended time limits (timely reperfusion) for ST-segment elevation myocardial infarction patients, exploring the impact of geography, patient characteristics and socio-economy. DESIGN: National register-based cohort study. SETTING: Multilevel logistic regression models were applied to examine the associations between timely reperfusion and residency in hospital referral areas and municipalities, patient characteristics, and socio-economy. PARTICIPANTS: 7607 Norwegian ST-segment elevation myocardial infarction patients registered in the Norwegian Registry of Myocardial Infarction during 2015-2018. MAIN OUTCOME MEASURES: The odds of timely reperfusion by primary percutaneous coronary intervention (PCI) or fibrinolysis. RESULTS: Among 7607 ST-segment elevation myocardial infarction patients in Norway, 56% received timely reperfusion. The Norwegian goal is 85%. While 81% of the patients living in the Oslo hospital referral area received timely reperfusion, only 13% of the patients living in Finnmark did so.Patients aged 75-84 years had lower odds of timely reperfusion than patients below 55 years of age (OR 0.73, 95% CI 0.61 to 0.87). Patients with moderate or high comorbidity had lower odds than patients without (OR 0.81, 95% CI 0.68 to 0.95 and OR 0.61, 95% CI 0.44 to 0.84). More than 2 hours from symptom onset to first medical contact gave lower odds than less than 30 min (OR 0.63, 95% CI 0.54 to 0.72). 1-2 hours of travel time to a PCI centre (OR 0.39, 95% CI 0.31 to 0.49) and more than 2 hours (OR 0.22, 95% CI 0.16 to 0.30) gave substantially lower odds than less than 1 hour of travel time. CONCLUSIONS: The varying proportion of patients receiving timely reperfusion across hospital referral areas implies inequity in fundamental healthcare services, not compatible with established Norwegian health policy. The importance of travel time to PCI centre points at the expanded use of prehospital pharmacoinvasive strategy to obtain the goals of timely reperfusion in Norway.

Socioeconomic and geographic differences in ablation of atrial fibrillation in Norway - a national cohort study.

BACKGROUND: The aim of this study was to analyse whether there are patient related or geographic differences in the use of catheter ablation among atrial fibrillation patients in Norway. METHODS: National population-based data on individual level of all Norwegians aged 25 to 75 diagnosed with atrial fibrillation from 2008 to 2017 were used to study the proportion treated with catheter ablation. Survival analysis, by Cox regression with attained age as time scale, separately by gender, was applied to examine the associations between ablation probability and educational level, income level, place of residence, and follow-up time. RESULTS: Substantial socioeconomic and geographic variation was documented. Atrial fibrillation patients with high level of education and high income were more frequently treated with ablation, and the education effect increased with increasing age. Patients living in the referral area of St. Olavs Hospital Trust had around three times as high ablation rates as patients living in the referral area of Finnmark Hospital Trust. CONCLUSIONS: Differences in health literacy, patient preference and demands are probably important causes of socioeconomic variation, and studies on how socioeconomic status influences the choice of treatment are warranted. Some of the geographic variation may reflect differences in ablation capacity. However, geographic variation related to differences in clinical practice and provider preferences implies a need for clearer guidelines, both at the specialist level and at the referring level.

Equitable access to cancer patient pathways in Norway - a national registry-based study.

BACKGROUND: In 2015, cancer patient pathways (CPP) were implemented in Norway to reduce unnecessary non-medical delay in the diagnostic process and start of treatment. The main aim of this study was to investigate the equality in access to CPPs for patients with either lung, colorectal, breast or prostate cancer in Norway. METHODS: National population-based data on individual level from 2015 to 2017 were used to study two proportions; i) patients in CPPs without the cancer diagnosis, and ii) cancer patients included in CPPs. Logistic regression was applied to examine the associations between these proportions and place of residence (hospital referral area), age, education, income, comorbidity and travel time to hospital. RESULTS: Age and place of residence were the two most important factors for describing the variation in proportions. For the CPP patients, inconsistent differences were found for income and education, while for the cancer patients the probability of being included in a CPP increased with income. CONCLUSIONS: The age effect can be related to both the increasing risk of cancer and increasing number of GP and hospital contacts with age. The non-systematic results for CPP patients according to income and education can be interpreted as equitable access, as opposed to the systematic differences found among cancer patients in different income groups. The inequalities between income groups among cancer patients and the inequalities based on the patients' place of residence, for both CPP and cancer patients, are unwarranted and need to be addressed.

Impact of parents' education on variation in hospital admissions for children: a population-based cohort study.

OBJECTIVES: To assess the impact of parental educational level on hospital admissions for children, and to evaluate whether differences in parents' educational level can explain geographic variation in admission rates. DESIGN: National cohort study. SETTING: The 18 hospital referral areas for children in Norway. PARTICIPANTS: All Norwegian children aged 1-16 years in the period 2008-2016 and their parents. MAIN OUTCOME MEASURES: Age- and gender-adjusted admission rates and probability of admission. RESULTS: Of 1 538 189 children, 156 087 (10.2%) had at least one admission in the study period. There was a nearly twofold (1.9) variation in admission rates between the hospital referral areas (3113 per 100 000 children, 95% CI: 3056 to 3169 vs 1627, 95% CI: 1599 to 1654). Area level variances in multilevel analysis did not change after adjusting for parental level of education. Children of parents with low level of education (maternal level of education, low vs high) had the highest admission rates (2016: 2587, 95% CI: 2512 to 2662 vs 1810, 95% CI: 1770 to 1849), the highest probability of being admitted (OR: 1.18, 95% CI: 1.16 to 1.20), the highest number of admissions (incidence rate ratio: 1.05, 95% CI: 1.01 to 1.10) and admissions with lower cost (-0.5%, 95% CI: -1.2% to 0.3%). CONCLUSIONS: Substantial geographic variation in hospital admission rates for children was found, but was not explained by parental educational level. Children of parents with low educational level had the highest admission probability, and the highest number of admissions, but the lowest cost of admissions. Our results suggest that the variation between the educational groups is not due to differences in medical needs, and may be characterised as unwarranted. However, the manner in which health professionals communicate and interact with parents with different educational levels might play an important role.

Variation in use of open and laparoscopic distal pancreatectomy and associated outcome metrics in a universal health care system.

BACKGROUND: Universal health care (UHC) should ensure equal access to and use of surgery, but few studies have explored variation in UHC systems. The objective was to describe practice of distal pancreatectomy in Norway covered exclusively by an UHC. METHODS: Data on all patients undergoing distal pancreatectomy from the Norwegian Patient Register over a 5-year period. Age- and gender-adjusted population-based resection rates (adj. per million/yr) for distal pancreatectomy were analysed across 4 regions and outcomes related to splenic salvage rate, hospital stay, reoperation, readmissions and 90-day mortality risk between regions. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). RESULTS: Regional difference exist in terms of absolute numbers, with the majority of procedures done in one region (n = 331; 59.7%). Regional variation persisted for age- and gender-adjusted population-rates, with highest rate at 23.8/million/yr and lowest rate at 13.5/mill/yr (for a 176% relative difference; or an absolute difference of +10.3 resections/million/yr). Overall, a lapDP instead of an open DP was 3.5 times more likely in SouthEast compared to all other regions combined (lapDP rate: 83% vrs 24%, respectively; OR 15.4, 95% c.i. 10.1-23.5; P < 0.001). The splenic salvage rate was lower in SouthEast (19.9%) compared to all other regions (average 26.5%; highest in Central-region at 37.0%; P = 0.010 for trend). Controlled for other factors in multivariate regression, 'region' of surgery remained significantly associated with laparoscopic access. CONCLUSION: Despite a universal health care system, considerable variation exists in resection rates, use of laparoscopy and splenic salvage rates across regions.

A nationwide cohort study of resection rates and short-term outcomes in open and laparoscopic distal pancreatectomy.

BACKGROUND: Distal pancreatectomy (DP) is increasingly done by laparoscopy but data from routine practise are scarce. We describe practise in a national cohort. METHODS: Data from the Norwegian Patient Register of all patients undergoing DP from 2012 to 2016. National resection rates were analysed. Short-term outcomes include length of stay, reoperation, readmissions and 90-day mortality. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). RESULTS: Of 554 procedures, 327 (59%) were laparoscopic. Median age was 66 years (iqr 55-72) and 52% were women. Resection rates increased during the period for all DP (from 1.76 to 2.39 per 100.000/yr), and significantly for laparoscopic DP (adjusted R-square 0.858; P = 0.015). Elderly patients had more resection (r2 = 0.11; P = 0.019). Splenectomy (n = 427; 77%) was less likely with laparoscopy (laparoscopy 72% vs open 84%, respectively; OR 0.64, 95% c.i. 0.42-0.97; P = 0.035). Multivisceral resections occurred more often in open DP (5.3% vs 1.2% for laparoscopy, OR 4.51, 1.44-14.2; P = 0.008). Reoperation occurred in 34 (6%), readmission in 109 (20%), and mortality in 8 (1.4%). Hospital stay was shorter for laparoscopic DP. CONCLUSION: Use of DP increases in the population, particularly in the elderly, with use of laparoscopic access and an association with a reduced hospital stay.

The effect of centralization on short term outcomes of pancreatoduodenectomy in a universal health care system.

BACKGROUND: Centralization of pancreatic resections is advocated due to a volume-outcome association. Pancreatic surgery is in Norway currently performed only in five teaching hospitals. The aim was to describe the short-term outcomes after pancreatoduodenectomy (PD) within the current organizational model and to assess for regional disparities. METHODS: All patients who underwent PD in Norway between 2012 and 2016 were identified. Mortality (90 days) and relaparotomy (30 days) were assessed for predictors including demographic data and multi-visceral or vascular resection. Aggregated length-of-stay and national and regional incidences of the procedure were also analysed. RESULTS: A total of 930 patients underwent PD during the study period. In-hospital mortality occurred in 20 patients (2%) and 34 patients (4%) died within 90 days. Male gender, age, multi-visceral resection and relaparotomy were independent predictors of 90-day mortality. Some 131 patients (14%) had a relaparotomy, with male gender and multi-visceral resection as independent predictors. There was no difference between regions in procedure incidence or 90-day mortality. There was a disparity within the regions in the use of vascular resection (p = 0.021). CONCLUSION: The short-term outcomes after PD in Norway are acceptable and the 90-day mortality rate is low. The outcomes may reflect centralization of pancreatic surgery.

Contemporary practice and short-term outcomes after liver resections in a complete national cohort.

BACKGROUND: Improved outcome after liver resections have been reported in several series, but outcomes from national cohorts are scarce. Our aim was to evaluate nationwide practice and short-term outcomes after liver surgery in a universal healthcare system. METHODS: A complete 5-year cohort of all liver resections from the Norwegian Patient Registry (NPR). Short-term outcomes were aggregated length of stay (a-LoS), reoperation and 90-day mortality. RESULTS: Of 2118 liver resections, 605 (28.6%) were major, median age was 65 years and 1184 (55%) were male. Most common indication was metastatic disease (n = 1554; 73.4%) and primary malignancy (n = 328; 15.3%). Laparoscopy was performed in 513 (33.9%) of minor and 37 (6.1%) of major liver resections and increased over time to 39.1% of minor resections in 2016. Median a-LoS was 12 days for major resections, 8 days for open minor and 3 days for laparoscopic minor resections. Reoperation was reported for 159 (7.4%) and 90-day mortality for 44 (2.1%). Primary malignancy, male gender, elderly patients and major resections were associated with poorer outcome. CONCLUSIONS: In a national cohort, laparoscopy is used for a substantial proportion of minor resections and was associated with reduced a-LoS. Risk factors for reoperation and mortality were male gender, increased age and major resection for primary malignancy.

Calculating the 30-day Survival Rate in Acute Myocardial Infarction: Should we Use the Treatment Chain or the Hospital Catchment Model?

INTRODUCTION: Acute myocardial infarction (AMI) is a potentially deadly disease and significant efforts have been concentrated on improving hospital performance. A 30-day survival rate has become a key quality of care indicator. In Northern Norway, some patients undergoing AMI are directly transferred to the Regional Cardiac Intervention Center at the University Hospital of North Norway in Tromsø. Here, coronary angiography and percutaneous coronary intervention is performed. Consequently, local hospitals may be bypassed in the treatment chain, generating differences in case mix, and making the treatment chain model difficult to interpret. We aimed to compare the treatment chain model with an alternative based on patients' place of living. METHODS: Between 2013 and 2015, a total of 3,155 patients were registered in the Norwegian Patient Registry database. All patients were categorized according to their local hospital's catchment area. The method of Guo-Romano, with an indifference interval of 0.02, was used to test whether a hospital was an outlier or not. We adjusted for age, sex, comorbidity, and number of prior hospitalizations. CONCLUSIONS: We revealed the 30-day AMI survival figure ranging between 88.0% and 93.5% (absolute difference 5.5%) using the hospital catchment method. The treatment chain rate ranged between 86.0% and 94.0% (absolute difference 8.0%). The latter figure is the one published as the National Quality of Care Measure in Norway. Local hospitals may get negative attention even though their catchment area is well served. We recommend the hospital catchment method as the first choice when measuring equality of care.

Major postoperative complications are associated with impaired long-term survival after gastro-esophageal and pancreatic cancer surgery: a complete national cohort study.

BACKGROUND: Some studies have reported an association between complications and impaired long-term survival after cancer surgery. We aimed to investigate how major complications are associated with overall survival after gastro-esophageal and pancreatic cancer surgery in a complete national cohort. METHODS: All esophageal-, gastric- and pancreatic resections performed for cancer in Norway between January 1, 2008, and December 1, 2013 were identified in the Norwegian Patient Registry together with data concerning major postoperative complications and survival. RESULTS: When emergency cases were excluded, there were 1965 esophageal-, gastric- or pancreatic resections performed for cancer in Norway between 1 January 2008, and 1 December 2013. A total of 248 patients (12.6 %) suffered major postoperative complications. Complications were associated both with increased early (90 days) mortality (OR = 4.25, 95 % CI = 2.78-6.50), and reduced overall survival when patients suffering early mortality were excluded (HR = 1.23, 95 % CI = 1.01-1.50). CONCLUSIONS: Major postoperative complications are associated with impaired long-term survival after gastro-esophageal and pancreatic cancer surgery.

Norwegian patients with colon cancer start their adjuvant therapy too late.

BACKGROUND: For patients with colon cancer who are to receive adjuvant chemotherapy according to national guidelines, such therapy must be initiated no more than 4-6 weeks after the surgical intervention. We wished to investigate whether these guidelines are being complied with. We also wished to see whether the type of surgery (open or laparoscopic) had any effect on the time elapsing before initiation of adjuvant therapy. MATERIAL AND METHOD: The material includes 1,132 patients who had undergone surgery for colon cancer in the period 2008-2013 and who received adjuvant chemotherapy. Surgical treatment and adjuvant chemotherapy are defined through diagnosis and procedural codes in the Norwegian Patient Register for the period 2008-2013. RESULTS: On average, 44.7 days passed after the surgical intervention before the patients commenced their adjuvant chemotherapy. For 49% of the patients, the adjuvant therapy was not initiated within the six-week deadline. Patients who had undergone laparoscopic surgery were hospitalised for shorter periods (6.5 days versus 10.7 days) and had fewer complications (7.6% versus 16.4%) when compared to patients who had undergone open surgery, yet still failed to start their adjuvant therapy correspondingly earlier. INTERPRETATION: Measures should be taken to improve quality, thus ensuring that the guidelines are complied with and that patients start their required adjuvant therapy earlier. For those who have undergone laparoscopic surgery, it ought to be simple to reap the gains from shorter hospitalisation periods and fewer complications in the form of a more rapid initiation of adjuvant therapy.

Total Synthesis and Biological Evaluation of Rakicidin†A and Discovery of a Simplified Bioactive Analogue.

We report a concise asymmetric synthesis of rakicidin A, a macrocyclic depsipeptide that selectively inhibits the growth of hypoxic cancer cells and stem-like leukemia cells. Key transformations include a diastereoselective organocatalytic cross-aldol reaction to build the polyketide portion of the molecule, a highly hindered ester fragment coupling reaction, an efficient Helquist-type Horner-Wadsworth-Emmons (HWE) macrocyclization, and a new DSC-mediated elimination reaction to construct the sensitive APD portion of rakicidin A. We further report the preparation of a simplified structural analogue (WY1) with dramatically enhanced hypoxia-selective activity.

Improving response rate and quality of survey data with a scratch lottery ticket incentive.

BACKGROUND: The quality of data collected in survey research is usually indicated by the response rate; the representativeness of the sample, and; the rate of completed questions (item-response). In attempting to improve a generally declining response rate in surveys considerable efforts are being made through follow-up mailings and various types of incentives. This study examines effects of including a scratch lottery ticket in the invitation letter to a survey. METHOD: Questionnaires concerning oral health were mailed to a random sample of 2,400 adults. A systematically selected half of the sample (1,200 adults) received a questionnaire including a scratch lottery ticket. One reminder without the incentive was sent. RESULTS: The incentive increased the response rate and improved representativeness by reaching more respondents with lower education. Furthermore, it reduced item nonresponse. The initial incentive had no effect on the propensity to respond after the reminder. CONCLUSION: When attempting to improve survey data, three issues become important: response rate, representativeness, and item-response. This study shows that including a scratch lottery ticket in the invitation letter performs well on all the three.

Smarter elder care? A cost-effectiveness analysis of implementing technology in elder care.

Whereas in most sectors, technology has taken over trivial and labour consuming tasks, this transformation has been delayed in the healthcare sector. Although appropriate technology is available, there is general resistance to substituting 'warm' hands with 'cold' technology. In the future, this may change as the number of elderly people increases relative to the people in the work force. In combination with an increasing demand for healthcare services, there are calls for efforts to increase productivity in the sector. Based on experience data from previous studies on information and communication technology efforts in the healthcare sector, we quantitatively assess the use of smart house technology and video visits in home care. Having identified healthcare providers, hospitals and relatives as the main affected groups, we show that smart house technology is cost-effective, even if only relatives gain from it. Video visits, which have higher implementation costs, demand effects on both relatives and health care providers in order to be a cost-effective tool in home care. As the analysis is purely quantitative, these results need to be complemented with qualitative effects and with more thorough discussions of the ethical, medical and legal aspects of the use of technology in home care.

Economic gains from electronic message exchange: the importance of working procedures.

BACKGROUND AND PURPOSE: There are several cost-benefit evaluations of introducing new technology for administrative purposes in the health care sector. Whereas some of these recognise the importance of adapting the working procedures to the new technology, very few look into the consequences of delays in adaptation to the new technology. In this paper, we focus on the consequences of keeping old working procedures, although new technology is implemented. METHODS: Based on on-site observations we have estimated the economic gains of implementing electronic message exchange in the health care sector depending on which working procedures are applied. Then we continue by using a dynamic cost-benefit analysis (CBA) in order to take into account that conversion to new working procedures takes place over time, and we demonstrate the loss in potential gains due to such a delay. RESULTS: Keeping working procedures fit to old technology when new technology is implemented may imply that only between 40 and 50% of the potential time savings (benefits) are realised. In a dynamic perspective, the keeping of double procedures for 10 years and more will jeopardise the economic gains for surgeries, whereas hospitals still may have an economic gain. The delay in conversion to new working procedures implies that only 50% of the dynamic net present value of the gains is realised. The longer it takes before the old procedures are abandoned the lower is the dynamic net present value of the gains. This is due to the discounting of future gains. CONCLUSIONS: These are all arguments for emphasising and putting resources into training and motivation programs for employees when new technology is being implemented. LIMITATIONS OF THE STUDY: We have only considered quantifiable effects of electronic message exchange in the health care sector, and only for hospitals and surgeries.