RESUMO
BACKGROUND: This paper investigates the consequences of the COVID-19 pandemic on mortality and hospitalization among nursing home residents in Norway. While existing evidence shows that nursing home residents were overrepresented among COVID-19-related deaths, suggesting inadequate protection measures, this study argues that the observed overrepresentation in mortality and hospitalization may partly stem from the inherent frailty of this demographic. Using nationwide administrative data, we assessed excess deaths and hospitalization by comparing pandemic-era rates to those of a pre-pandemic cohort. METHODS: We compared mortality and hospitalization rates between a pandemic cohort of nursing home residents as of September 2019 (N = 30,052), and a pre-pandemic cohort as of September 2017 (N = 30,429). Both cohorts were followed monthly for two years, beginning in September 2019 and 2017, respectively. This analysis was conducted at the national level and separately for nursing home residents in areas with low, medium, and high SARS-CoV-2 community transmission. Event studies and difference-in-difference models allowed us to separate the impact of the pandemic on mortality and hospitalization from secular and seasonal changes. RESULTS: The pandemic cohort experienced a non-significant 0.07 percentage points (95% confidence interval (CI): - 0.081 to 0.221) increase in all-cause mortality during the 18 months following pandemic onset, compared to the pre-pandemic cohort. Moreover, our findings indicate a substantial reduction in hospitalizations of 0.27 percentage points (95% CI: - 0.464 to - 0.135) and a non-significant decrease of 0.80 percentage points (95% CI: - 2.529 to 0.929) in the proportion of nursing home residents hospitalized before death. The effect on mortality remained consistent across regions with both high and low levels of SARS-CoV-2 community transmission. CONCLUSIONS: Our findings indicate no clear evidence of excess all-cause mortality in Norway during the pandemic, neither nationally nor in areas with high infection rates. This suggests that early implementation of nationwide and nursing home-specific infection control measures during the pandemic effectively protected nursing home residents. Furthermore, our results revealed a decrease in hospitalizations, both overall and prior to death, suggesting that nursing homes adhered to national guidelines promoting on-site treatment for residents.
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COVID-19 , Hospitalização , Casas de Saúde , Humanos , COVID-19/mortalidade , COVID-19/epidemiologia , Casas de Saúde/estatística & dados numéricos , Noruega/epidemiologia , Masculino , Idoso , Hospitalização/estatística & dados numéricos , Feminino , Idoso de 80 Anos ou mais , Estudos de Coortes , SARS-CoV-2 , Sistema de Registros , PandemiasRESUMO
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.
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Infarto do Miocárdio , Intervenção Coronária Percutânea , Humanos , Infarto do Miocárdio/terapia , Hospitais , Intervenção Coronária Percutânea/efeitos adversos , Comorbidade , Mortalidade Hospitalar , Resultado do TratamentoRESUMO
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.
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Insuficiência Cardíaca/economia , Cuidado Transicional/economia , Idoso , Análise Custo-Benefício , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Masculino , Alta do Paciente , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Cuidado Transicional/estatística & dados numéricosRESUMO
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.
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Acidentes por Quedas/prevenção & controle , Fraturas do Quadril/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Serviços de Saúde Comunitária , Exercício Físico , Feminino , Fraturas do Quadril/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Noruega , Avaliação de Resultados em Cuidados de Saúde , Educação de Pacientes como Assunto , Qualidade de VidaRESUMO
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.
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Recessão Econômica/estatística & dados numéricos , Assistência ao Paciente/estatística & dados numéricos , Desemprego/estatística & dados numéricos , Idoso , Europa (Continente) , Feminino , Inquéritos Epidemiológicos , Humanos , Assistência de Longa Duração , MasculinoRESUMO
AIMS: Maintaining continuity of care between doctors and patients is considered a fundamental aspect of quality in primary healthcare. In this study, we aim to examine continuity in Norway over time by computing two commonly used indicators of continuity: the St Leonard's Index of Continuity of Care (SLICC) and the Usual Provider of Care Index (UPC). METHOD: We employ individual-level data, which covers all primary care consultations. This data includes the identities of each patient and physician, and we can identify each patient's regular general practitioner (GP). The SLICC is calculated as the share of consultations conducted by the patient's regular GP annually from 2006 to 2021. Additionally, we identify each patient's most visited physician and compute the UPC as the share of total consultations conducted by the most visited physician during the same period. Our analysis is conducted at the national level and stratified according to the level of centrality, differentiating between areas of high, moderate, and low centrality. RESULTS: Our findings reveal that, at the national level, SLICC and UPC exhibit remarkable stability, reaching 64 and 71 percent, respectively, in 2021. However, there is significant geographical variation, with the least central areas experiencing less continuous healthcare (SLICC at 49 percent in 2021) than patients residing in more central areas (SLICC at 68 in 2021). CONCLUSION: Our results demonstrate a high degree of continuity that has been stable over time. However, large geographical variations suggest that policymakers should strive to reduce geographical disparities in healthcare quality.
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Continuidade da Assistência ao Paciente , Medicina Geral , Noruega , Humanos , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Medicina Geral/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Atenção Primária à Saúde/estatística & dados numéricos , Idoso , Clínicos Gerais/estatística & dados numéricos , Qualidade da Assistência à SaúdeRESUMO
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.
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Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Idoso , Cidades , NoruegaRESUMO
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.