Tailored implementation of national recommendations on fall prevention among older adults in municipalities in Norway (FALLPREVENT trial): a study protocol for a cluster-randomised trial.

BACKGROUND: Despite substantial research evidence indicating the effectiveness of a range of interventions to prevent falls, uptake into routine clinical practice has been limited by several implementation challenges. The complexity of fall prevention in municipality health care underlines the importance of flexible implementation strategies tailored both to general determinants of fall prevention and to local contexts. This cluster-randomised trial (RCT) investigates the effectiveness of a tailored intervention to implement national recommendations on fall prevention among older home-dwelling adults compared to usual practice on adherence to the recommendations in health professionals. METHODS: Twenty-five municipalities from four regions in Norway will be randomised to intervention or control arms. Each municipality cluster will recruit up to 30 health professionals to participate in the study as responders. The tailored implementation intervention comprises four components: (1) identifying local structures for implementation, (2) establishing a resource team from different professions and levels, (3) promoting knowledge on implementation and fall prevention and (4) supporting the implementation process. Each of these components includes several implementation activities. The Consolidated Framework for Implementation Research (CFIR) will be used to categorise determinants of the implementation process and the Expert Recommendations for Implementing Change (ERIC) will guide the matching of barriers to implementation strategies. The primary outcome measure for the study will be health professionals' adherence to the national recommendations on fall prevention measured by a questionnaire. Secondary outcomes include injurious falls, the feasibility of the intervention, the experiences of the implementation process and intervention costs. Measurements will be carried out at baseline in August 2023, post-intervention in May 2024 and at a follow-up in November 2024. DISCUSSION: This study will provide evidence on the effectiveness, intervention costs and underlying processes of change of tailored implementation of evidence-based fall prevention recommendations. TRIAL REGISTRATION: The trial is registered in the Open Science Registry: https://doi.org/10.17605/OSF.IO/JQ9T5 . Registered: March 03, 2023.

When health trumps money: Economic incentives and health equity in the public provision of nursing homes in Norway.

The allocation of public care services should be determined by individual needs, but can be influenced by economic factors. This paper examines the impact of economic incentives on the allocation of public nursing home care in the Norwegian long-term care system. In Norway, municipalities and city districts have economic incentives for choosing nursing home care for high-income individuals in need of care and home-based care in sheltered housing for low-income individuals. The study uses a theoretical model and empirical data from the municipality of Oslo to determine if nursing home spots are allocated based on income, which would be financially advantageous for the city districts. We do not find evidence that the economic incentives of the care provider play a role in the allocation of nursing homes. Thus, in this setting, needs seem to be the dominant factor for allocation of nursing home care, while economic incentives seem to play no significant role. The clear legal mandate to provide services based on needs only is likely an important factor in this.

Effect of hospital assignment on mortality for AMI patients.

BACKGROUND: International guidelines recommend percutaneous coronary intervention (PCI) to treat acute myocardial infarction (AMI) if PCI can be performed within two hours. PCI is a centralized treatment, and therefore a common trade-off is whether to send AMI patients directly to a hospital that performs PCI, or postpone a potential PCI-treatment by first receiving acute treatment at a local hospital that can not perform PCI. In this paper, we estimate the effect of sending patients directly to a PCI-hospital on AMI mortality. METHODS: Using nation-wide individual-level data from 2010 to 2015, we studied mortality rates for AMI patients sent directly to a hospital that performs PCI (N=20 336) compared to AMI patients sent to a hospital not performing PCI (N=33 437). Since the underlying health of patients may affect both hospital assignment and mortality, estimates from traditional multivariate risk adjustment models are likely biased. We therefore apply an instrumental variable (IV) model using the historical municipal share sent directly to a PCI-hospital as an instrument for being sent directly to a PCI-hospital. RESULTS: Patients sent directly to a PCI-hospital are younger and have fewer comorbidities than patients who are first sent to a non-PCI-hospital. IV results suggest that those initially sent to PCI-hospitals have 4.8 percentage points decrease (95% CI (- 18.1)-8.5) in mortality after one month compared to those initially sent to non-PCI-hospitals. CONCLUSION: Our IV results suggest that there is a non-significant decrease in mortality for AMI patients sent directly to a PCI hospital. The estimates are too imprecise to conclude that health personnel should change their practice and send more patients directly to a PCI-hospital. Moreover, the results may be taken to suggest that health personnel navigate AMI patients to the best treatment option.

Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure.

Background: Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks. Objective: To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care. Design: Decision analytic microsimulation model. Data Sources: Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data. Target Population: Patients with HF who were aged 75 years at hospital discharge. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Disease management clinics, nurse home visits (NHVs), and nurse case management. Outcome Measures: Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis: All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained. Results of Sensitivity Analysis: Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained. Limitation: Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings. Conclusion: In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF. Primary Funding Source: Swiss National Science Foundation, Research Council of Norway, and an Intermountain-Stanford collaboration.

The impact of community-based interventions for the older population: a quasi-experimental study of a hip-fracture prevention program in Norway.

BACKGROUND: Hip fractures among older adults are a major public health problem in many countries. Hip fractures are associated with expensive health care treatments, and serious adverse effects on patients' health and quality-of-life. In this paper, we estimate the effect of a community-based hip fracture prevention program that was initiated in 16 Norwegian municipalities in 2007. Specifically, the participating municipalities implemented one or more of the following interventions: exercise programs for older adults, information and education campaigns to communicate how to effectively reduce falls to care workers and older adults, and preventive home safety assessment and modification help services. METHODS: We used a difference-in-difference design, and identified control municipalities by matching on pre-intervention trends in the outcome. The outcome measure was the incidence of hip-fractures among older adults (≥65 years). RESULTS: We found no statistically significant effects of the implemented program on the incidence of hip fractures, on average, in older subgroups (≥80 years) or in municipality-specific analyses. CONCLUSIONS: It is unclear whether the interventions managed to achieve a change in hip fracture rates at the population level.

Careful in the Crisis? Determinants of Older People's Informal Care Receipt in Crisis-Struck European Countries.

Macroeconomic downturns can have an important impact on the receipt of informal and formal long-term care, because recessions increase the number of unemployed and affect net wealth. This paper investigates how the market for informal care changed during and after the Great Recession in Europe, with particular focus on the determinants of care receipt. We use data from the Survey of Health, Ageing and Retirement in Europe, which includes a rich set of variables covering waves before and after the Great Recession. We find evidence of an increase in the availability of informal care after the economic downturn when controlling for year and country fixed effects. This trend is mainly driven by changes in care provision of individuals not cohabiting with the care recipient. We also find evidence of several determinants of informal care receipt changing during the crisis - such as physical needs, personal wealth, and household structures. Copyright © 2016 John Wiley & Sons, Ltd.