Spouses of Stroke Survivors Report Reduced Health-Related Quality of Life Even in Long-Term Follow-Up: Results From Sahlgrenska Academy Study on Ischemic Stroke.

BACKGROUND AND PURPOSE: The consequences for the family of stroke survivor are generally studied in a short-term perspective. The aim of this study was to assess long-term aspects of health-related quality of life among spouses of stroke survivors. METHODS: Data on stroke survivors, controls, and spouses were collected from the 7-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). The health-related quality of life of spouses was assessed by the Short Form-36, and the characteristics of stroke survivors were assessed using the National Institutes of Health Stroke Scale, the Mini-Mental State Examination, the Hospital Anxiety and Depression Scale, the Barthel Index, and the modified Rankin Scale. RESULTS: Dyads of 248 stroke survivors aged <70 at stroke onset and 245 dyads of matched controls were included. Spouses of stroke survivors and spouses of controls had a median age of 64 and 65, respectively; proportion of men was 35% and 34%, respectively. The spouses of stroke survivors reported lower scores in all the mental domains (P=0.045; P<0.001), as well as in the domains of general health (P=0.013) and physical role (P=0.006), compared with the spouses of controls. Predictors of poor physical health of the spouses were their own age and the level of global disability of the stroke survivor. Predictors of poor mental health of the spouses were depressive symptoms, cognitive impairment, and global disability among the stroke survivors. CONCLUSIONS: The health-related quality of life of spouses of stroke survivors is reduced not only during the first years but also in the long-term perspective.

How to create and terminate a school of public health.

The famous preamble to the Constitution of the World Health Organization (WHO) from 1948, stating that health is not only the absence of disease, has been one of the most influential political statements of our time. The follow-up, reaching a position where health is viewed as instrumental to a good life and not as a goal in itself, as set out in the Ottawa Charter of 1986, has likewise been of the utmost importance for the global development of public health, as well as developing the concept of health promotion. The focus on public health sparked by the WHO was paralleled by expansion of the academic interest in the topic, beginning in the USA and successively adopted around the world. In the Nordic countries the pioneering of an academic platform for public health studies and research began in 1953. This was later followed by a stepwise expansion to a full academic institution with postgraduate studies, work-related training, research and development. From the start, the resultant institution called the Nordic School of Public Health (NHV) was a joint Nordic project financed by the Nordic governments. The NHV became a leader in public health studies in Nordic countries and also a role model for the development of an academic community. A large campus and a select and erudite staff, together with thousands of students, paved the way for the NHV having a major impact on public health policy in Nordic countries. One effect of this was increasing awareness of the need for systematic policy supporting public health research and, with this, the founding of institutions of public health in all of the separate Nordic countries. Ironically, the impact made by the NHV in spreading the idea of public health as an important part of academic study has made the NHV superfluous. It is true that courses and programmes in public health are now available at most universities in the five Nordic countries, but they are directed at young students fresh from high school. There is no institution that offers a broad and high-quality postgraduate education and training in public health, adapted to the special needs of mid-career professionals in a multi-professional and internordic setting. With the NHV closing, a research institute focusing public health in a Nordic context will disappear, as will an internationally leading School of Public Health, a centre of excellence and relevance in public health, which has evaluated, assessed and promoted the goals and evaluated the success of the Nordic welfare societies.

Health services management and research at Nordic School of Public Health.

In Anglo-Saxon countries the subject of health services research has long been an important academic theme. In the Nordic countries, however, this research and training area has been limited and partly hidden by integration into various other sections at universities and colleges. In this respect the Nordic School of Public Health was an exception, as the provision of managerial skills to healthcare professionals and persons working with public health was the backbone of the school during all 60 years. A variety of research in health services management, as well as publications of text books, accompanied the presented courses. Several of the scholars have earned important positions in international networks and editorial boards, as well as in boards for assessments of research grants. In the near future, this academic field will require alternative support.

Economic burden of stroke in a large county in Sweden.

BACKGROUND: Stroke remains to be a major burden of disease, often causing death or physical impairment or disability. This paper estimates the economic burden of stroke in a large county of 1.5 million inhabitants in western Sweden. METHODS: The economic burden of stroke was estimated from a societal perspective with an incidence approach. Data were collected from clinical registries and 3,074 patients were included. In the cost calculations, both direct and indirect costs were estimated and were based on costs for 12 months after a first-ever stroke. RESULTS: The total excess costs in the first 12 months after the first-ever stroke for a population of 1.5 million was 629 million SEK (€69 million). Men consumed more acute care in hospitals, whereas women consumed more rehabilitation and long-term care provided by the municipalities. Younger patients brought a significantly higher burden on society compared with older patients due to the loss of productivity and the increased use of resources in health care. CONCLUSIONS: The results of this cost-of-illness study were based on an improved calculation process in a number of fields and are consistent with previous studies. In essence, 50% of costs for stroke care fall on acute care hospital, 40% on rehabilitation and long-time care and informal care and productivity loss explains 10% of total cost for the stroke disease. The result of this study can be used for further development of the methods for economic analyses as well as for analysis of improvements and investments in health care.

Does ambulance use differ between geographic areas? A survey of ambulance use in sparsely and densely populated areas.

AIM: The aim of this study was to analyze possible differences in the use of ambulance service between densely and sparsely populated areas. METHODS: This study was designed as a 2-step consecutive study that included the ambulance service in 4 different areas with different geographical characteristics. A specific questionnaire was distributed to the enrolled ambulance services. Completion of one questionnaire was required for each ambulance mission, that is, 1 per patient, during the study periods. For calculations of P values, geographic area was treated as a 4-graded ordered variable, from the most densely populated to the most sparsely populated (ie, urban-suburban-rural-remote rural area). Statistical tests used were Mann-Whitney U test and Spearman rank statistic, when appropriate. All P values are 2 tailed and considered significant if below .01. RESULTS: The medical status of the patients in the prehospital care situation was more often severe in the sparsely populated areas. In addition, drugs were more often used in the ambulances in these areas. In the sparsely populated areas, ambulance use was more frequently judged as the appropriate mode of transportation compared with the more densely populated areas. CONCLUSIONS: Our study suggests that the appropriateness of the use of ambulance is not optimal. Furthermore, our data suggest that geographical factors, that is, population density, is related to inappropriate use. Thus, strategies to improve the appropriateness of ambulance use should probably take geographical aspects into consideration.

Initial emergency medical dispatching and prehospital needs assessment: a prospective study of the Swedish ambulance service.

OBJECTIVES: To evaluate the setting of priorities and patients' need for the ambulance service. METHODS: A prospective, consecutive study was conducted during a 6-week period. The ambulance staff completed a questionnaire assessing each patient's need for prehospital care. In addition to the questionnaire, data were extracted from the ambulance medical records for each case. RESULTS: The study included 1977 ambulance assignments. The results show that there is a substantial safety margin in the priority assessments made by the emergency medical dispatch operators, where the ambulance staff support the safety margin for initial priorities, despite the lack of at-the-scene confirmation. At-the-scene assessments indicated that 10% of all patients had potentially life-threatening conditions or no signs of life, but the advanced life support units were not systematically involved in these serious cases. The results even showed that one-third of the patients for whom an ambulance was assigned did not need the ambulance service according to the assessment made by the ambulance staff. CONCLUSION: Using the criteria-based dispatch protocol, the personnel at the emergency medical dispatch centres work with a safety margin in their priority assessments for ambulance response. Generally, this 'overtriage' and safety margin for initial priority settings were supported as appropriate by the ambulance staff. According to the judgement of the ambulance staff, one-third of all the patients who were assigned an ambulance response did not require ambulance transport.

Why are people without medical needs transported by ambulance? A study of indications for pre-hospital care.

OBJECTIVE: The purpose of this report was to describe the characteristics of patients transported by ambulance, in spite of being evaluated by the ambulance staff at the scene as not requiring prehospital care. A second aim was to compare these patients with those judged as being in need of this care. METHODS: Three ambulance service districts located in different rural and metropolitan geographical areas were included in the study and all three were covered by a single emergency dispatch centre. Following the dispatch of ambulances, the staff assessed and recorded the medical needs of the patients at the scene, according to a questionnaire developed for the study. In addition to the questionnaire, data were extracted from the ambulance medical records database for each patient. If the patients were just transported by ambulance without receiving any other prehospital intervention, they were assessed as not being in need of the emergency service. The evaluation included events at the scene and during transportation. The ambulance staff making the needs assessments were emergency medical technicians and registered nurses. In this report, 604 patients who did not require prehospital care are described and compared with the remaining group of patients who required this care (1373). For analysis, descriptive statistics were used to analyse the data. RESULTS: The ambulance staff assessed that, among patients reported by the emergency medical dispatch centre as having abdominal or urinary problems, 42% did not need the ambulance service. Even among intrahospital transports (patients for whom medical personnel made the request for an ambulance), 45% did not require ambulance transport, as judged by the ambulance staff. Among patients reported by the emergency medical dispatch centre as having chest pain or other heart symptoms or trauma/accidents, respectively, only small percentages (18%) and (17%) did not require the ambulance service, as assessed by the ambulance staff. Most of the patients without obvious medical needs had been allocated an ambulance response for nonurgent conditions, that is priority level 2 or 3, but patients without medical needs were even found at the highest priority level 1. Of the patients who did not require an ambulance, more than half (55%) would have been able to get to a hospital in their own car or by taxi, whereas the remainder of the patients needed a transport vehicle in which they could lie down, but which was not equipped and staffed like an ambulance. CONCLUSION: Among the patients transported by the emergency medical service system in the study areas, a significant percentage were judged by the ambulance staff as not being in need of prehospital interventions. The majority were transported by a fully equipped emergency medical ambulance to an emergency medical department at a hospital, without requiring any prehospital interventions either at the scene or during transportation. The emergency medical service organization has to develop clear criteria for the utilization of ambulance services that can be accepted and implemented by the dispatch centres and by healthcare personnel. These criteria need to include safety margins and at the same time enable the appropriate use of resources.

Decentralized responsibility for costs of outpatient prescription pharmaceuticals in Sweden. Assessment of models for decentralized financing of subsidies from a management perspective.

In this study, models for decentralization of responsibility for costs of subsidised outpatient prescription pharmaceuticals within the county councils in Sweden were studied. The aims of the decentralization were to cut the escalating costs associated with risk sharing mechanisms on a national level and to integrate utilization of drugs into the priority process in health care. History of development and the characteristics of the solutions on county level were identified, described and analysed from taped interviews with relevant persons in central management positions in the selected counties. Information was supplemented from documentation. Two main models were found, a population based model and a prescriber based. In the population based model, family medicine in primary care was responsible for subsidies of drugs classified as "basic" (80%) regardless of prescriber. In this model, hospital departments were responsible for the "special" drugs (20%) regardless of prescriber. In the prescriber based model each provider was responsible for costs of its own prescribing. We found that the prescriber based model was chosen for the strong incentives for cost containment, while the population based model was expected to focus more on service to patients. This reform was based on the assumption that incentives for cost containment on an organisational level are effective. Experiences from other reforms in health care support this hypothesis. This means that there is a risk that cost containment jeopardises medical decisions on patient level.

Spinal cord injured persons' conceptions of hospital care, rehabilitation, and a new life situation.

BACKGROUND: The basic aim of spinal cord injury (SCI) rehabilitation is to help patients return to a life worth living. It is therefore important that the staff at spinal units and rehabilitation centres understand how the patients experience their rehabilitation and their adjustment process to the new situation. AIM: To describe SCI persons' experiences of their rehabilitation process. METHOD: Nineteen SCI persons were interviewed. Data from the tape-recorded interviews were analysed according to a modified descriptive version of the phenomenographic analysis process. RESULTS: Six categories that describe the informants' conceptions of their rehabilitation process emerged: access to information, participation in planning rehabilitation, emotional support, feelings of vulnerability, adjustment to a new life situation, and emotional consequences of the injury. CONCLUSION: Straightforward information, participation in the planning of the rehabilitation programme and emotional support were important factors influencing the rehabilitation process after the SCI. Professionals working with SCI rehabilitation should make use of patients' experiences in order to develop better rehabilitation programmes that focus on the individual needs of the patient. People are individuals and failure to take this into account can impact negatively on quality of life and the effectiveness of the rehabilitation.