Preterm birth and asthma and COPD in adulthood: a nationwide register study from two Nordic countries.

BACKGROUND: Preterm birth affects lungs in several ways but few studies have follow-up until adulthood. We investigated the association of the entire spectrum of gestational ages with specialist care episodes for obstructive airway disease (asthma and chronic obstructive pulmonary disease (COPD)) at age 18-50 years. METHODS: We used nationwide registry data on 706 717 people born 1987-1998 in Finland (4.8% preterm) and 1 669 528 born 1967-1999 in Norway (5.0% preterm). Care episodes of asthma and COPD were obtained from specialised healthcare registers, available in Finland for 2005-2016 and in Norway for 2008-2017. We used logistic regression to estimate odds ratios (ORs) for having a care episode with either disease outcome. RESULTS: Odds of any obstructive airway disease in adulthood for those born at <28 or 28-31 completed weeks were 2-3-fold of those born full term (39-41 completed weeks), persisting after adjustments. For individuals born at 32-33, 34-36 or 37-38 weeks, the odds were 1.1- to 1.5-fold. Associations were similar in the Finnish and the Norwegian data and among people aged 18-29 and 30-50 years. For COPD at age 30-50 years, the OR was 7.44 (95% CI 3.49-15.85) for those born at <28 weeks, 3.18 (95% CI 2.23-4.54) for those born at 28-31 weeks and 2.32 (95% CI 1.72-3.12) for those born at 32-33 weeks. Bronchopulmonary dysplasia in infancy increased the odds further for those born at <28 and 28-31 weeks. CONCLUSION: Preterm birth is a risk factor for asthma and COPD in adulthood. The high odds of COPD call for diagnostic vigilance when adults born very preterm present with respiratory symptoms.

Health personnel's perceptions of pressure on capacity in the specialist health services. / Helsepersonells oppfattelse av kapasitetspress i spesialisthelsetjenesten.

BACKGROUND: Increasing the utilisation of unused capacity in hospitals is a health policy goal, but there is concern that little unused capacity remains. The objective of the study was to examine how healthcare personnel experience and deal with pressure on capacity in the somatic specialist health services. MATERIAL AND METHOD: In this qualitative study, we conducted semi-structured interviews with unit heads and doctors and nurses involved in discharging patients in two Norwegian hospital trusts. Nine interviews (both individual and group) with altogether 19 informants were carried out in the period October 2017-February 2018. The interviews were analysed using systematic text condensation. RESULTS: Pressure on hospital capacity was described as continual pressure to treat more patients. The informants used the term 'undercapacity': a situation in which increased demands without sufficient resources were detrimental to something or someone. Elderly patients who had completed their treatment and were waiting for the provision of municipal services were regarded as particularly vulnerable, since they were often overrepresented among the patients moved between departments and wards in order to free up capacity when beds were urgently needed. The hospital staff felt they had little influence on the type of municipal services the patients were offered following discharge. INTERPRETATION: The informants stated that their daily work was negatively affected by undercapacity. Health professionals' perceptions of pressure on hospital capacity constitute vital knowledge in policy formation in the field.

Time of admission and mortality after hip fracture: a detailed look at the weekend effect in a nationwide study of 55,211 hip fracture patients in Norway.

Background and purpose - There are numerous studies on the weekend effect for hip fracture patients, with conflicting results. We analyzed time of admission and discharge, and the association with mortality and length of hospital stay in more detail. Patients and methods - We used data from 61,211 surgically treated hip fractures in 55,211 patients, admitted to Norwegian hospitals 2008-2014. All patients were aged 50 years or older. Data were analyzed with Cox and Poisson regression. Results - Mortality within 30 days did not differ substantially by day of admission, although admissions on Sundays and holidays had a slightly increased mortality. The hazard ratios were 1.1 (95% confidence interval [CI] 0.97-1.2) for Sundays, and 1.2 (CI 0.98-1.4) for holidays, relative to Mondays. For patients admitted between 6:00 am and 7:00 am the hazard ratio was 1.4 (CI 1.1-1.8) relative to patients admitted between 2:00 pm and 3:00 pm. Discharges during weekends and holidays were associated with a substantial higher mortality than weekday discharges. Patients admitted from Friday to Sunday generally stayed in hospital for a shorter time than patients admitted during other days. Interpretation - Our results indicate that the discussion on weekday versus weekend admission effects might have distracted attention from other important factors, such as time of day of admission, and day of discharge from hospital treatment.

Using machine learning to assess the extent of busy ambulances and its impact on ambulance response times: A retrospective observational study.

BACKGROUND: Ambulance response times are considered important. Busy ambulances are common, but little is known about their effect on response times. OBJECTIVE: To assess the extent of busy ambulances in Central Norway and their impact on ambulance response times. DESIGN: This was a retrospective observational study. We used machine learning on data from nearby incidents to assess the probability of up to five different ambulances being candidates to respond to a medical emergency incident. For each incident, the probability of a busy ambulance was estimated by summing the probabilities of candidate ambulances being busy at the time of the incident. The difference in response time that may be attributable to busy ambulances was estimated by comparing groups of nearby incidents with different estimated busy probabilities. SETTING: Medical emergency incidents with ambulance response in Central Norway from 2013 to 2022. MAIN OUTCOME MEASURES: Prevalence of busy ambulances and differences in response times associated with busy ambulances. RESULTS: The estimated probability of busy ambulances for all 216,787 acute incidents with ambulance response was 26.7% (95% confidence interval (CI) 26.6 to 26.9). Comparing nearby incidents, each 10-percentage point increase in the probability of a busy ambulance was associated with a delay of 0.60 minutes (95% CI 0.58 to 0.62). For incidents in rural and urban areas, the probability of a busy ambulance was 21.6% (95% CI 21.5 to 21.8) and 35.0% (95% CI 34.8 to 35.2), respectively. The delay associated with a 10-percentage point increase in busy probability was 0.81 minutes (95% CI 0.78 to 0.84) and 0.30 minutes (95% CI 0.28 to 0.32), respectively. CONCLUSION: Ambulances were often busy, which was associated with delayed ambulance response times. In rural areas, the probability of busy ambulances was lower, although the potentially longer delays when ambulances were busy made these areas more vulnerable.

Preterm birth and the risk of multimorbidity in adolescence: a multiregister-based cohort study.

BACKGROUND: Multimorbidity affects people of all ages, but the risk factors of multimorbidity in adolescence are unclear. The aim of this study was to examine preterm birth (<37 weeks) as a shared risk factor for multiple health outcomes and the role of gestational age (degree of prematurity) in the development of increasingly complex multimorbidity (two, three, or four health outcomes) in adolescence (age 10-18 years). METHODS: We used population-wide data from Finland (1 187 610 adolescents born 1987-2006) and Norway (555 431 adolescents born 1998-2007). Gestational age at birth was ascertained from medical birth registers and categorised as 23-27 weeks (extremely preterm), 28-31 weeks (very preterm), 32-33 weeks (moderately preterm), 34-36 weeks (late preterm), 37-38 weeks (early term), 39-41 weeks (term, reference category) and 42-44 weeks (post-term). Children who died or emigrated before their 10th birthday, and those with missing or implausible data on gestational age, birthweight, or covariates, were excluded. Health outcomes at age 10-18 years were ascertained from specialised health care and mortality registers. We calculated hazard ratios (HRs) and population attributable fractions (PAFs) with 95% CIs for multiple health outcomes during adolescence. FINDINGS: Individuals were followed up from age 10 to 18 years (mean follow-up: 6 years, SD: 3 years). Preterm birth was associated with increased risks of 20 hospital-treated malignant, cardiovascular, endocrinological, neuropsychiatric, respiratory, genitourinary, and congenital health outcomes, after correcting for multiple testing and ignoring small effects (HR <1·2). Confounder-adjusted HRs comparing preterm with term-born adolescents were 2·29 (95% CI 2·19-2·39) for two health outcomes (PAF 9·0%; 8·3-9·6), and 4·22 (3·66-4·87) for four health outcomes (PAF 22·7%; 19·4-25·8) in the Finnish data. Results in the Norwegian data showed a similar pattern. We observed a consistent dose-response relationship between an earlier gestational age and elevated risks of increasingly complex multimorbidity in both datasets. INTERPRETATION: Preterm birth is associated with increased risks of diverse multimorbidity patterns at age 10-18 years. Adolescents with a preterm-born background could benefit from diagnostic vigilance directed at multimorbidity and a multidisciplinary approach to health care. FUNDING: European Union Horizon 2020, Academy of Finland, Foundation for Pediatric Research, Sigrid Jusélius Foundation, Signe and Ane Gyllenberg Foundation.

General practitioners ending their practice and impact on patients' health, healthcare use and mortality: a protocol for national registry cohort studies in Norway, 2008 to 2021.

INTRODUCTION: Continuous general practitioner (GP) and patient relations associate with positive health outcomes. Termination of GP practice is unavoidable, while consequences of final breaks in relations are less explored. We will study how an ended GP relation affects patient's healthcare utilisation and mortality compared with patients with a continuous GP relation. METHODS AND ANALYSIS: We link national registries data on individual GP affiliation, sociodemographic characteristics, healthcare use and mortality. From 2008 to 2021, we identify patients whose GP stopped practicing and will compare acute and elective, primary and specialist healthcare use and mortality, with patients whose GP did not stop practicing. We match GP-patient pairs on age and sex (both), immigrant status and education (patients), and number of patients and practice period (GPs). We analyse the outcomes before and after an ended GP-patient relation, using Poisson regression with high-dimensional fixed effects. ETHICS AND DISSEMINATION: This study protocol is part of the approved project Improved Decisions with Causal Inference in Health Services Research, 2016/2159/REK Midt (the Regional Committees for Medical and Health Research Ethics) and does not require consent. HUNT Cloud provides secure data storage and computing. We will report using the STROBE guideline for observational case-control studies and publish in peer-reviewed journals, accessible in NTNU Open and present at scientific conferences. To reach a broader audience, we will summarise articles in the project's web page, regular and social media, and disseminate to relevant stakeholders.

Gestational age at birth and hospitalisations for infections among individuals aged 0-50 years in Norway: a longitudinal, register-based, cohort study.

Background: Preterm birth is associated with increased risk of childhood infections. Whether this risk persists into adulthood is unknown and limited information is available on risk patterns across the full range of gestational ages. Methods: In this longitudinal, register-based, cohort study, we linked individual-level data on all individuals born in Norway (January 01, 1967-December 31, 2016) to nationwide hospital data (January 01, 2008-December 31, 2017). Gestational age was categorised as 23-27, 28-31, 32-33, 34-36, 37-38, 39-41, and 42-44 completed weeks. The analyses were stratified by age at follow-up: 0-11 months and 1-5, 6-14, 15-29, and 30-50 years. The primary outcome was hospitalisation due to any infectious disease, with major infectious disease groups as secondary outcomes. Adjusted hospitalisation rate ratios (RRs) for any infection and infectious disease groups were estimated using negative binomial regression. Models were adjusted for year of birth, maternal age at birth, parity, and sex, and included an offset parameter adjusted for person-time at risk. Findings: Among 2,695,830 individuals with 313,940 hospitalisations for infections, we found a pattern of higher hospitalisation risk in lower gestational age groups, which was the strongest in childhood but still evident in adulthood. Comparing those born very preterm (28-31) and late preterm (34-36) to full-term (39-41 weeks), RRs (95% confidence interval) for hospitalisation for any infectious disease at ages 1-5 were 3.3 (3.0-3.7) and 1.7 (1.6-1.8), respectively. At 30-50 years, the corresponding estimates were 1.4 (1.2-1.7) and 1.2 (1.1-1.3). The patterns were similar for the infectious disease groups, including bacterial and viral infections, respiratory tract infections (RTIs), and infections not attributable to RTIs. Interpretation: Increasing risk of hospitalisations for infections in lower gestational age groups was most prominent in children but still evident in adolescents and adults. Possible mechanisms and groups that could benefit from vaccinations and other prevention strategies should be investigated. Funding: St. Olav's University Hospital and Norwegian University of Science and Technology, Norwegian Research Council, Liaison Committee for education, research and innovation in Central Norway, European Commission, Academy of Finland, Sigrid Jusélius Foundation, Foundation for Pediatric Research, and Signe and Ane Gyllenberg Foundation.

Educational inequalities in disability pensioning - the impact of illness and occupational, psychosocial, and behavioural factors: The Nord-Trøndelag Health Study (HUNT).

AIMS: Socioeconomic inequalities in disability pensioning are well established, but we know little about the causes. The main aim of this study was to disentangle educational inequalities in disability pensioning in Norwegian women and men. METHODS: The baseline data consisted of 32,948 participants in the Norwegian Nord-Trøndelag Health Study (1995-97), 25-66 years old, without disability pension, and in paid work. Additional analyses were made for housewives and unemployed/laid-off persons. Information on the occurrence of disability pension was obtained from the National Insurance Administration database up to 2008. Data analyses were performed using Cox regression. RESULTS: We found considerable educational inequalities in disability pensioning, and the incidence proportion by 2008 was higher in women (25-49 years 11%, 50-66 years 30%) than men (25-49 years 6%, 50-66 years 24%). Long-standing limiting illness and occupational, psychosocial, and behavioural factors were not sufficient to explain the educational inequalities: young men with primary education had a hazard ratio of 3.1 (95% CI 2.3-4.3) compared to young men with tertiary education. The corresponding numbers for young women were 2.7 (2.1-3.1). We found small educational inequalities in the oldest women in paid work and no inequalities in the oldest unemployed/laid-off women and housewives. CONCLUSIONS: Illness and occupational, psychosocial, and behavioural factors explained some of the educational inequalities in disability pensioning. However, considerable inequalities remain after accounting for these factors. The higher incidence of disability pensioning in women than men and the small or non-existing educational inequalities in the oldest women calls for a gender perspective in future research.

Education-based health inequalities in 18,000 Norwegian couples: the Nord-Trøndelag Health Study (HUNT).

BACKGROUND: Education-based inequalities in health are well established, but they are usually studied from an individual perspective. However, many individuals are part of a couple. We studied education-based health inequalities from the perspective of couples where indicators of health were measured by subjective health, anxiety and depression. METHODS: A sample of 35,980 women and men (17,990 couples) was derived from the Norwegian Nord-Trøndelag Health Study 1995-97 (HUNT 2). Educational data and family identification numbers were obtained from Statistics Norway. The dependent variables were subjective health (four-integer scale), anxiety (21-integer scale) and depression (21-integer scale), which were captured using the Hospital Anxiety and Depression Scale. The dependent variables were rescaled from 0 to 100 where 100 was the worst score. Cross-sectional analyses were performed using two-level linear random effect regression models. RESULTS: The variance attributable to the couple level was 42% for education, 16% for subjective health, 19% for anxiety and 25% for depression. A one-year increase in education relative to that of one's partner was associated with an improvement of 0.6 scale points (95% confidence interval = 0.5-0.8) in the subjective health score (within-couple coefficient). A one-year increase in a couple's average education was associated with an improvement of 1.7 scale points (95% confidence interval = 1.6-1.8) in the subjective health score (between-couple coefficient). There were no education-based differences in the anxiety or depression scores when partners were compared, whereas there were substantial education-based differences between couples in all three outcome measures. CONCLUSIONS: We found considerable clustering of education and health within couples, which highlighted the importance of the family environment. Our results support previous studies that report the mutual effects of spouses on education-based inequalities in health, suggesting that couples develop their socioeconomic position together.

Trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors: repeated cross-sectional surveys from the Nord-Trøndelag Health Study (HUNT) 1984-2008.

BACKGROUND: There has been an overall decrease in incident ischaemic heart disease (IHD), but the reduction in IHD risk factors has been greater among those with higher social position. Increased social inequalities in IHD mortality in Scandinavian countries is often referred to as the Scandinavian "public health puzzle". The objective of this study was to examine trends in absolute and relative educational inequalities in four modifiable ischaemic heart disease risk factors (smoking, diabetes, hypertension and high total cholesterol) over the last three decades among Norwegian middle-aged women and men. METHODS: Population-based, cross-sectional data from The Nord-Trøndelag Health Study (HUNT): HUNT 1 (1984-1986), HUNT 2 (1995-1997) and HUNT 3 (2006-2008), women and men 40-59 years old. Educational inequalities were assessed using the Slope Index of Inequality (SII) and The Relative Index of Inequality (RII). RESULTS: Smoking prevalence increased for all education groups among women and decreased in men. Relative and absolute educational inequalities in smoking widened in both genders, with significantly higher absolute inequalities among women than men in the two last surveys. Diabetes prevalence increased in all groups. Relative inequalities in diabetes were stable, while absolute inequalities increased both among women (p = 0.05) and among men (p = 0.01). Hypertension prevalence decreased in all groups. Relative inequalities in hypertension widened over time in both genders. However, absolute inequalities in hypertension decreased among women (p = 0.05) and were stable among men (p = 0.33). For high total cholesterol relative and absolute inequalities remained stable in both genders. CONCLUSION: Widening absolute educational inequalities in smoking and diabetes over the last three decades gives rise to concern. The mechanisms behind these results are less clear, and future studies are needed to assess if educational inequalities in secondary prevention of IHD are larger compared to educational inequalities in primary prevention of IHD. Continued monitoring of IHD risk factors at the population level is therefore warranted. The results emphasise the need for public health efforts to prevent future burdens of life-style-related diseases and to avoid further widening in socioeconomic inequalities in IHD mortality in Norway, especially among women.

How do busy hospital circumstances affect mortality and readmission within 60 days: A cohort study of 680 000 acute admissions in Norway.

OBJECTIVE: To study mortality and readmissions for older patients admitted during more and less busy hospital circumstances. DESIGN: Cohort study where we identified patients that were admitted to the same hospital, during the same month and day of the week. We estimated effects of inflow of acute patients and the number of concurrent acute inpatients. Mortality and readmissions were analysed using stratified Cox-regression. SETTING: All people 80 years and older acutely admitted to Norwegian hospitals between 2008 and 2016. MAIN OUTCOME MEASURES: Mortality and readmissions within 60 days from admission. RESULTS: Among 294 653 patients with 685 197 admissions, mean age was 86 years (standard deviation 5). Overall, 13% died within 60 days. An interquartile range difference in inflow of acute patients was associated with a hazard ratio (HR) of 0.99, 95% confidence interval (95% CI) 0.98 to 1.00). There was little evidence of differences in readmissions, but a 7% higher risk (HR 1.07, 95% CI 1.06 to 1.09) of being discharged outside ordinary daytime working hours. CONCLUSIONS: Older patients admitted during busier circumstances had similar mortality and readmissions to those admitted during less busy periods. Yet, they showed a higher risk of discharge outside daytime working hours. Despite limited effects of busyness on a hospital level, there could still be harmful effects of local situations.

High ward occupancy, bedspacing, and 60 day mortality for patients with myocardial infarction, stroke, and heart failure.

AIMS: To study the consequences of crowded wards among patients with cardiovascular disease. METHODS AND RESULTS: This is a cohort study among 201 801 patients with 258 807 admissions who were acutely admitted for myocardial infarction (N = 107 895), stroke (N = 87 336), or heart failure (N = 63 576) to any Norwegian hospital between 2008 and 2016. The ward admitting most patients with the given clinical condition was considered a patient's home ward. We compared patients with the same condition admitted when home ward occupancy was different, at the same hospital and during comparable time periods. Occupancy was standardized such that a one-unit difference corresponded to the interquartile range in occupancy in the given month. One interquartile increase in home ward occupancy was associated with 7% higher odds of admission to an alternate ward [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.09 to 1.11], and length of stay was shorter (-0.10 days, 95% CI -0.18 to -0.09). Patients with heart failure had 15% higher odds of admission to alternate wards (OR 1.15, 95% CI 1.08 to 1.23) and increased mortality [hazard ratio (HR) 1.08, 95% CI 1.03 to 1.15]. We found no apparent effect on mortality for patients with myocardial infarction (HR 0.99, 95% CI 0.94 to 1.05) or stroke (HR 1.00, 95% CI 0.96 to 1.05). CONCLUSIONS: Patients with heart failure had higher risk of admission to alternate wards when home ward occupancy was high. These patients may be negatively affected by full wards.

The predictive ability of self-rated health on ischaemic heart disease and all-cause mortality in elderly women and men: the Nord-Trondelag Health Study (HUNT).

BACKGROUND: the aim of this study was to assess the predictive ability of self-rated health (SRH) on ischaemic heart disease (IHD) and all-cause mortality in elderly women and men. METHODS: a total of 5,808 participants aged ≥ 70 years with no diagnosed atherosclerotic diseases at baseline in the Nord-Trøndelag Health Study (HUNT 2, 1995-97) were followed for 10 years. Participants provided data on psychosocial, behavioural and biomedical factors. The association between SRH and mortality was assessed using Cox proportional hazard model. RESULTS: the SRH below good was reported by 50% of the women and 35% of the men. For SRH below good, the mortality from IHD was 1.62 (1.14-2.29) in women and 1.23 (0.91-6.67) in men. The corresponding adjusted hazard risk ratio for all-cause mortality was 1.59 (1.38-1.83) in women and 1.43 (1.26-1.63) in men. CONCLUSIONS: poor SRH predicted mortality in elderly people. For older women, the predictive value of poor SRH was higher than that of men, and this was true independent of age, marital status, diabetes, any limiting long-standing illness and selected biomedical, behavioural and psychosocial factors. These results are in contrast to most studies on the SRH-mortality association in elderly people. Further theoretical and empirical studies are needed to identify the particular factors that should be taken into account when elderly women and men rate their own health.

High volumes of recent surgical admissions, time to surgery, and 60-day mortality.

AIMS: Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. METHODS: This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. RESULTS: Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). CONCLUSION: A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264-270.

Adolescents' health-related dietary patterns by parental socio-economic position, the Nord-Trøndelag Health Study (HUNT).

BACKGROUND: Nutrition is among the important determinants of diseases, and the social patterning of early eating habits may offer keys to prevention. We studied associations between selected indicators of adolescents' health-related dietary habits (daily intake of candy, soft drinks, fruit and vegetables) and parental socio-economic position (education, social class and income). METHODS: The material consisted of participants in the adolescent part (Young-HUNT) of the Nord-Trøndelag Health Study during the period 1995-97, 8817 girls and boys aged 13-19 years (89% of all students in junior high schools and high schools in a Norwegian county). Data on parental socio-economic position was available from the adult part of HUNT and Statistics Norway. Cross-sectional data analyses were performed using cross-tables and binary logistic regression. RESULTS: Of the indicators of socio-economic position used, the parent's educational level, in particular the mother's education, showed the highest impact on adolescents' health-related dietary habits. Girls with the least educated mothers had a prevalence odds ratio of 2.5 (1.8-3.3) for drinking soft drinks daily and 0.6 (0.5-0.8) for eating vegetables daily as compared to girls with the most educated mothers. The corresponding numbers for boys were 1.9 (1.5-2.4) and 0.6 (0.5-0.8). Parental social class also showed gradients in adolescents' health-related dietary habits, but there was virtually no gradient by income. CONCLUSION: Higher levels of parental education, in particular the mother's education, are clearly associated with healthier dietary habits among adolescents. This social patterning should be recognized in public health interventions.

Hospitals´ Discharge Tendency and Risk of Death - An Analysis of 60,000 Norwegian Hip Fracture Patients.

PURPOSE: A reduction in the length of hospital stay may threaten patient safety. This study aimed to estimate the effect of organizational pressure to discharge on 60-day mortality among hip fracture patients. PATIENTS AND METHODS: In this cohort study, hip fracture patients were analyzed as if they were enrolled in a sequence of trials for discharge. A hospital's discharge tendency was defined as the proportion of patients with other acute conditions who were discharged on a given day. Because the hospital's tendency to discharge would affect hip fracture patients in an essentially random manner, this exposure could be regarded as analogous to being randomized to treatment in a clinical trial. The study population consisted of 59,971 Norwegian patients with hip fractures, hospitalized between 2008 and 2016, aged 70 years and older. To calculate the hospital discharge tendency for a given day, we used data from all 5,013,773 other acute hospitalizations in the study period. RESULTS: The probability of discharge among hip fracture patients increased by 5.5 percentage points (95% confidence interval (CI)=5.3-5.7) per 10 percentage points increase in hospital discharges of patients with other acute conditions. The increased risk of death that could be attributed to a discharge from organizational causes was estimated to 3.7 percentage points (95% CI=1.4-6.0). The results remained stable under different time adjustments, follow-up periods, and age cut-offs. CONCLUSION: This study showed that discharges from organizational causes may increase the risk of death among hip fracture patients.

The effect of emergency department delays on 30-day mortality in Central Norway.

OBJECTIVE: To assess whether prolonged length of stay in the emergency department was associated with risk of death. METHODS: We analysed data from 165,183 arrivals at St. Olav's University Hospital's emergency department from 2011 to 2018, using an instrumental variable method. As instruments for prolonged length of emergency department stay, we used indicators measured before arrival of the patient. These indicators were used to study the association between prolonged length of emergency department stay and risk of death, being discharged from the emergency department and length of hospitalisation for those who were hospitalised. RESULTS: Mean length of stay in the emergency department was 2.9 hours, and 30-day risk of death was 3.4%. Per hour prolonged length of stay in the emergency department, the overall change in risk of death was close to zero, with a narrow 95% confidence interval of -0.5 to 0.7 percentage points. Prolonged emergency department stay was associated with a higher probability of being discharged from the emergency department without admission to the hospital. We found no substantial differences in length of hospitalisation for patients who were admitted. CONCLUSION: In this study, prolonged emergency department stay was not associated with increased risk of death.