The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

BACKGROUND: General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. METHODS: Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach. RESULTS: Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. CONCLUSION: Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.

Time is money: general practitioners' reflections on the fee-for-service system.

BACKGROUND: Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions. METHODS: We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis. RESULTS: We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees. CONCLUSIONS: GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

Patients' narratives of their patient participation in the myocardial infarction pathway.

AIM: To explore how patients in areas without local percutaneous coronary intervention (PCI) facilities experience patient participation in different phases of the myocardial infarction pathway. BACKGROUND: Acute treatment of myocardial infarction often involves PCI. In Norway, this treatment is centralized at certain hospitals; thus, patients often require long-distance transportation and experience frequent hospital transfers. Short hospital stays, transfers between hospitals and the patient's emotional state pose challenges to promoting patient participation. DESIGN: A qualitative design with a narrative approach. METHODS: Participants were recruited through purposive sampling. Eight men and two women were interviewed in 2016. FINDINGS: Four themes related to the patients' experiences at the beginning, middle and end of the pathway were identified: (a) Lack of verbal communication in the acute phase; (b) trust in healthcare professionals and treatment; (c) lack of participation and coordination at discharge; and (d) shared decision-making in rehabilitation. The findings showed how the patients moved from a low level of patient participation in the acute phase to a high level of patient participation in the rehabilitation phase. CONCLUSION: This is the first study to explore patient participation in different phases of the myocardial infarction pathway. We argue that individual plans for information and patient participation are important to improve patient involvement in an earlier stage of the pathway. Further research from a healthcare professional perspective can be valuable to understand this topic. IMPACT: This study gives new insight that can be valuable for healthcare professionals in implementing patient participation throughout the pathway.

The development and feasibility of a personal health-optimization system for people with bipolar disorder.

BACKGROUND: People with bipolar disorder often experience ill health and have considerably reduced life expectancies. Suboptimal treatment is common and includes a lack of effective medicines, overtreatment, and non-adherence to medical interventions and lifestyle measures. E- and m-health applications support patients in optimizing their treatment but often exhibit conceptual and technical shortcomings. The objective of this work was to develop and test the usability of a system targeting suboptimal treatment and compare the service to other genres and strategies. METHODS: Based on the frameworks of shared decision-making, multi-criteria decision analysis, and single-subject research design, we interviewed potential users, reviewed research and current approaches, and created a first version using a rapid prototyping framework. We then iteratively improved and expanded the service based on formative usability testing with patients, healthcare providers, and laypeople from Norway, the UK, and Ukraine. The evidence-based health-optimization system was developed using systematic methods. The System Usability Scale and a questionnaire were administered in formative and summative tests. A comparison of the system to current standards for clinical practice guidelines and patient decision aids was performed. RESULTS: Seventy-eight potential users identified 82 issues. Driven by user feedback, the limited first version was developed into a more comprehensive system. The current version encompasses 21 integrated core features, supporting 6 health-optimization strategies. One crucial feature enables patients and clinicians to explore the likely value of treatments based on mathematical integration of self-reported and research data and the patient's preferences. The mean ± SD (median) system usability score of the patient-oriented subsystem was 71 ± 18 (73). The mean ± SD (median) system usability score in the summative usability testing was 78 ± 18 (75), well above the norm score of 68. Feedback from the questionnaire was generally positive. Eighteen out of 23 components in the system are not required in international standards for patient decision aids and clinical practice guidelines. CONCLUSION: We have developed the first evidence-based health-optimization system enabling patients, clinicians, and caregivers to collaborate in optimizing the patient's health on a shared platform. User tests indicate that the feasibility of the system is acceptable.

[«A most strange instance of illness in several siblings¼--first description of a rare neurological disease in 1830?]. / «Et høist mærkeligt Sygdomstilfælde hos flere Sødskende¼--en norsk førstegangsbeskrivelse fra 1830?

Was district medical officer Jensen the first doctor to describe patients with Pantothenate Kinase-Associated Neurodegeneration (PKAN) in Volda in 1830? A case series of four siblings with the same disease written by district medical officer Peter Jensen (1799-1832) in Aalesund in 1830, was published in the Norwegian medical journal Eyr in 1832. The children, who were healthy almost up to school age, developed dystonic involuntary movements and deformities in all extremities, lost their ability to speak and were emaciated before they died at around the age of nine years. Further information about the family and a fifth affected child has been found in the parish records. The clinical picture is consistent with Pantothenate Kinase-Associated Neurodegeneration (PKAN), a rare condition with basal ganglia iron deposition, described in 1922 by the German neuropathologists Julius Hallervorden (1882-1965) and Hugo Spatz (1888-1969). The disease was formerly called Hallervorden-Spatz syndrome, but because of the medical activities undertaken by these two researchers before and during the Second World War, this eponym is no longer recommended.

Authorship: attitudes and practice among Norwegian researchers.

BACKGROUND: Attitudes to, and practices of, scientific authorship vary. We have studied this variation among researchers in a university hospital and medical school in Norway. METHODS: We invited all faculty, researchers and PhD students at Oslo University Hospital and the Faculty of Medicine, University of Oslo (approximately 2700) by e-mail to answer a web-based questionnaire in January 2013. We asked the researchers to report their authorship experiences and to score their agreement with, and ability to practice according to, 13 statements on authorship qualifications and criteria on a five-point Likert scale (1 = completely agree, 5 = completely disagree). The statements were taken from the International Committee of Medical Journal Editors (ICMJE) and other recommendations on authorship. RESULTS: 654 questionnaires were returned (response rate 24%); 25% of the respondents had published less than five scientific articles, 43% five to 49, and 32% more than 50 articles. 97% reported knowledge of defined authorship criteria, and 68% regarded breaches of these as scientific misconduct. 36% had experienced pressure to include undeserved authors in their papers, more in basic science (46%) than in community medicine (25%). 29% reported that they had been denied authorship they believed they deserved. Researchers with less than six years of research experience found authorship decisions more difficult than more experienced researchers (48% vs 30%).The respondents' agreement with the statements on authorship was higher than their self-reported ability to follow them for all statements. Average scores for agreement and practice for all statements combined were 1.4 vs 2.3. The discrepancy between attitude and practice declined with publishing experience. For the core ICMJE authorship requirements the average difference between attitude and practice was 1.2 among those who had published less than 5 articles and 0.7 among those who had published 50 articles or more (p < 0.05). CONCLUSIONS: Almost all the responding researchers had knowledge of formal authorship requirements. Most of them agreed with the criteria, but found it harder to put them into practice. More experienced researchers found decisions on authorship and about the order of authors easier than less experienced researchers.

Cultural and musical activity among Norwegian doctors.

BACKGROUND: The cultural and musical activity of Norwegian doctors was studied in 1993. We wished to re-examine their cultural and musical activity, analyse the development and study the correlation with satisfaction, health and other leisure activities. MATERIAL AND METHOD: In the autumn of 2010, a survey was undertaken among a representative sample of economically active Norwegian doctors. The survey asked the same questions as in 1993, and the responses were also compared to the population studies conducted by Statistics Norway. We also used a cultural index that we have developed ourselves. RESULTS: Altogether 1,019 doctors (70%) responded to the survey. They reported a higher level of cultural activity in 2010 than in 1993, measured in terms of reading of non-medical literature and visits to the cinema, theatre and concerts. The doctors engaged in musical activity of their own especially frequently: 58% reported to be able to play an instrument, and 21% reported to play on a regular basis, which is more than among other academic professions. We found a significant correlation between the doctors' level of cultural activity and their job satisfaction, general satisfaction, self-reported health and physical activity. The doctors who engage most frequently in cultural activities are thus most satisfied with their work and with life in general. Furthermore, they also have better self-reported health. INTERPRETATION: Norwegian doctors give priority to cultural and musical activities. The assertion that doctors are particularly fond of music is more than just a myth.

Poor title--poor manuscript?

BACKGROUND: The title of a scientific article is important for several reasons. Does the title of a manuscript submitted for publication in a medical journal reflect the quality of the manuscript itself? MATERIAL AND METHOD: We prepared criteria for poor, fair and good titles and tested them in pilot studies. All manuscripts submitted to the Journal of the Norwegian Medical Association during the period 1 September 2009-31 August 2011 as original articles (n = 211) or review articles (n = 110) were recorded. The quality of the titles was scored by two former editors. Primary outcome measures were rejection rates and odds ratio for rejection of manuscripts with a poor title compared to those with a good title. RESULTS: For original articles, the rejection rate for manuscripts with a poor, fair or good title amounted to 88%, 73% and 61% (p = 0.002) respectively, and for review articles 83%, 56% and 38% (p < 0.001). The odds ratio for rejection of manuscripts with a poor title compared to those with a good title was 4.6 (95% CI: 1.7-12.3) for original articles and 8.2 (95% CI: 2.6-26.4) for review articles. In a logistic regression model, the quality of the title explained 14% and 27% of the variance in outcome for original articles and review articles respectively. INTERPRETATION: In this study, a poor manuscript title was significantly associated with manuscript rejection. This indicates that the quality of the title often reflects the quality of the manuscript itself.

Training physicians in providing complex information to patients with multiple sclerosis: a randomised controlled trial.

OBJECTIVE: To evaluate the effect of a specific communication training for neurologists on how to provide complex information about treatment options to patients with multiple sclerosis (MS). DESIGN: Single-centre, single-blind, randomised controlled trial. SETTING: One university hospital in Norway. PARTICIPANTS: Thirty-four patients with early-stage MS. INTERVENTION: A 3-hour training for neurologists on how to provide complex information about MS escalation therapy. MAIN OUTCOME MEASURES: Patient recall rate, measured with a reliable counting system of provided and recalled information about drugs. SECONDARY OUTCOME MEASURES: Number of information units provided by the physicians. Effects on patient involvement through questionnaires. METHODS: Patients with MS were instructed to imagine a disease development and were randomised and blinded to meet a physician to receive information on escalation therapy, before or after the physician had participated in a 3-hour training on how to provide complex information. Consultations and immediate patient recall interviews were video-recorded and transcribed verbatim. RESULTS: Patient recall rate was 0.37 (SD=0.10) pre-intervention and 0.39 (SD=0.10) post-intervention. The effect of the intervention on recall rate predicted with a general linear model covariate was not significant (coefficient parameter 0.07 (SE 0.04, 95% CI (-0.01 to 0.15)), p=0.099).The physicians tended to provide significantly fewer information units after the training, with an average of 91.0 (SD=30.3) pre-intervention and 76.5 (SD=17.4) post-intervention; coefficient parameter -0.09 (SE 0.02, 95% CI (-0.13 to -0.05)), p<0.001. There was a significant negative association between the amount of provided information and the recall rate (coefficient parameter -0.29 (SE 0.05, 95% CI (-0.39 to -0.18)), p<0.001). We found no significant effects on patient involvement using the Control Preference Scale, Collaborate or Four Habits Patient Questionnaire. CONCLUSION: A brief course for physicians on providing complex information reduced the amount of information provided, but did not improve patient recall rate. TRIAL REGISTRATION NUMBER: ISRCTN42739508.

Changes in life expectancy and disease burden in Norway, 1990-2019: an analysis of the Global Burden of Disease Study 2019.

BACKGROUND: Geographical differences in health outcomes are reported in many countries. Norway has led an active policy aiming for regional balance since the 1970s. Using data from the Global Burden of Disease Study (GBD) 2019, we examined regional differences in development and current state of health across Norwegian counties. METHODS: Data for life expectancy, healthy life expectancy (HALE), years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) in Norway and its 11 counties from 1990 to 2019 were extracted from GBD 2019. County-specific contributors to changes in life expectancy were compared. Inequality in disease burden was examined by use of the Gini coefficient. FINDINGS: Life expectancy and HALE improved in all Norwegian counties from 1990 to 2019. Improvements in life expectancy and HALE were greatest in the two counties with the lowest values in 1990: Oslo, in which life expectancy and HALE increased from 71·9 years (95% uncertainty interval 71·4-72·4) and 63·0 years (60·5-65·4) in 1990 to 81·3 years (80·0-82·7) and 70·6 years (67·4-73·6) in 2019, respectively; and Troms og Finnmark, in which life expectancy and HALE increased from 71·9 years (71·5-72·4) and 63·5 years (60·9-65·6) in 1990 to 80·3 years (79·4-81·2) and 70·0 years (66·8-72·2) in 2019, respectively. Increased life expectancy was mainly due to reductions in cardiovascular disease, neoplasms, and respiratory infections. No significant differences between the national YLD or DALY rates and the corresponding age-standardised rates were reported in any of the counties in 2019; however, Troms og Finnmark had a higher age-standardised YLL rate than the national rate (8394 per 100 000 [95% UI 7801-8944] vs 7536 per 100 000 [7391-7691]). Low inequality between counties was shown for life expectancy, HALE, all level-1 causes of DALYs, and exposure to level-1 risk factors. INTERPRETATION: Over the past 30 years, Norway has reduced inequality in disease burden between counties. However, inequalities still exist at a within-county level and along other sociodemographic gradients. Because of insufficient Norwegian primary data, there remains substantial uncertainty associated with regional estimates for non-fatal disease burden and exposure to risk factors. FUNDING: Bill & Melinda Gates Foundation, Research Council of Norway, and Norwegian Institute of Public Health.