Stayin' alive: The introduction of municipal in-patient acute care units was associated with reduced mortality and fewer hospital readmissions.

BACKGROUND: Integrated care is seen as integral in combating the current and projected resource scarcity in the healthcare systems of developed economies. Previous research finds positive effects from implementing intermediate care but there is a lack of research on how this shift towards care integration has affected traditional quality indicators within healthcare, indicators such as mortality rates and hospital readmissions. We seek to contribute to the discourse by studying how the introduction of intermediate care in the form of municipal acute units (MAUs) in Norway has affected age adjusted mortality rates and hospital readmissions. DATA AND METHODS: In this retrospective cohort study we utilize yearly population-based registry data from 2010 to 2016, analysed with fixed-effects regressions. Data on the implementation, characteristics and localization of the MAUs were gathered by telephone during the implementation period. Data on mortality rates and hospital readmissions were collected from Statistics Norway and the Norwegian patient registry. RESULTS: Our analyses finds that the introduction of MAU was associated with a statistically significant reduction in both aggregated mortality rates and hospital readmission rates. In depth analyses finds that our results are contingent upon the age of the patients treated at the MAUs and the clinical characteristics of the medical units themselves. CONCLUSION: Our findings indicate that the shift towards intermediate care through the introduction of MAUs has increased performance within the public healthcare sector in Norway. Our findings indicate that the introduction of MAU have had a positive public health impact by lowering the mortality and readmission rates for the oldest population cohort in Norway. Our findings suggests that countries with comparatively similar healthcare systems as Norway could achieve similar benefits from implementing intermediate care in the form of somatic medical institutions in the local communities.

(I can't get no) satisfaction: A comparative study of healthcare recommodification in Europe, 2010-18.

European health reforms during the last decades have strengthened patient rights and introduced choice, competition and financial incentives in a sector that has typically been state-directed and centrally controlled. The marketisation of health care has also drawn out profit and introduced private provision. The main argument behind this trend is that market competition will improve service quality and deliver health services more efficiently. Such reforms often fall under the umbrella of New Public Management (NPM), and there is a lack of empirical research on their effects. The purpose of this paper is to investigate the association between healthcare marketisation and health system outcomes across European nations. In order to measure a country's degree of healthcare marketisation we employed indicators of healthcare decommodification. The concept refers to the extent to which an individual's access to healthcare is dependent upon their market position and the extent to which a country's provision of health is independent from the market. These indicators are three measures that assess the financing, provision and coverage of the private sector, and thus reflects the varied role of the market in a health care system: private health care expenditure as amount of GDP, private hospital beds as amount of total hospital bed stock, and public healthcare coverage. As indicator of health system outcome, we employed a measure that has not previously been investigated in the context of healthcare marketisation: satisfaction with health care system. We used multilevel analyses on five waves (2009-2017) of the biannual European Social Survey (ESS), with our final models including more than 120,000 individuals from 21 countries. Our methodological approach allowed us to study both cross-sectional and longitudinal relationships. The strongest substantial associations were between coverage and satisfaction, with high public healthcare coverage being associated with higher satisfaction.

Let's stick together: The role of self-interest and ideological beliefs for supporting a 'solidaristic' health policy in Norway.

Previous studies of health system legitimacy have almost exclusively paid attention to patterns of service satisfaction and preference for state involvement. These two dimensions are related to substantial and procedural justice; i.e. the value of a certain policy and the way it is implemented. This study contributes to the research field by focusing on a third dimension that have been little studied so far: the willingness of citizens to contribute on a solidaristic basis. This dimension was captured through three health policy preferences: public healthcare spending willingness, opposition to co-payments and opposition to private health insurance. Building on the literature on welfare state legitimacy, the empirical model distinguished between two sets of predictors to explain individual differences: self-interest and ideological belief. Old age, poor health and poor economy is positively associated with opposition to co-payments for "self-inflicted" diseases, while low education and poor health is positively related to support for more public spending. Increasing age is furthermore positively associated with opposing co-payments and easier uptake of insurance. Liberal-conservative voters are less willing to spend more on healthcare but more willing to increase the use of co-payments and insurance.

'Professional-supportive' versus 'economic-operational' management: the relationship between leadership style and hospital physicians' organisational climate.

BACKGROUND: Health systems across the world have implemented reforms that call for a reconsideration of the role of management in hospitals, which is increasingly seen as important for performance. These reorganisation efforts of the hospitals have challenged and supplemented traditional profession-based management with more complex systems of management inspired by the business sector. Whereas there is emerging evidence on how medical professionals in their role as leaders and managers adapt to the new institutional logics of the health care sector with increasing demands for efficiency and budgetary discipline, no previous studies have investigated whether leaders' emphasis on clinical or financial priorities is related to how hospital physicians' view their working situation. The purpose of this study was therefore to examine the relationship between leadership style and hospital physicians' organisational climate. METHODS: We utilised data from a survey among 3000 Norwegian hospital physicians from 2016. The analysis used three additive indexes as dependent variables to reflect various aspects of the organisational climate: social climate, innovation climate and engagement at the workplace. The variables reflecting leadership style were based on an item in the survey asking the respondents to rate the leadership qualities of their proximate leaders (department chair) on 11 specific dimensions. We used factor analysis to identify two types of leadership styles: a traditional profession-based leadership style that emphasises the promotion of professional standards and quality in patient treatment, and a leadership style that reflects the emerging management philosophy with focus on economic administration and budgetary control. Controlling for demographic background, leader role, foreign medical exam and specialty, the empirical model was estimated via multivariate regression. RESULTS: The results documented a clear relationship between leadership style and organisational climate: a 'professional-supportive' leadership style is associated with better social climate, innovation climate and engagement at the workplace, while an 'economic-operational' leadership style is associated with a poorer social climate. CONCLUSIONS: The cross-sectional study design makes it impossible to draw inferences about direction of causality and causal pathways. However, the positive relationship between professional-supportive leadership and organisational climate is a matter, which should be seriously considered regardless of direction of causality.

Is a Decentralised Health Policy Associated With Better Self-rated Health and Health Services Evaluation? A Comparative Study of European Countries.

BACKGROUND: While decentralisation has come to be a major policy strategy in many healthcare systems, there is still insufficient evidence about its impact. Most studies have been of developing countries, and they have provided mixed results. This study is the first to test the relevance of political decentralisation across European countries, thus meeting the demand for more studies of decentralisation in developed countries, and building on an indicator of decentralisation reflecting the allocation of authority for both health policy tasks and health policy areas. METHODS: As indicators of health system outcome, we employed 2 measures that have not previously been investigated in the context of decentralisation: self-rated health and satisfaction with healthcare system. Using multilevel modelling and controlling for individual-level demographic and socioeconomic variables, the paper utilised the 2014 (7th) and 2016 (8th) round of the European Social Survey (ESS), including more than 70 000 individuals from 20 countries. RESULTS: The results suggest that decentralisation has a positive and significant association with health system satisfaction, but not with self-rated health. Of the different operationalisations, decentralised healthcare provision had the strongest association with health system satisfaction. CONCLUSIONs: Our study fails to provide clear support for decentralised health systems. There is a need for more research on the impact of such reforms in order to provide policy-makers with knowledge of desirable governance, organisational designs, management and incentives in healthcare.

Financial incentives and patient selection: Hospital physicians' views on cream skimming and economic management focus in Norway.

This paper uses survey data to analyse physician views on the risk of cream skimming under a system with activity based financing (ABF) for hospital services. We used data from two nation-wide physician surveys. A survey undertaken in 2006 captures views following a large NPM-inspired structural reform in 2002. In contrast, a survey undertaken in 2016 captures views after a period of a higher degree of institutional and financial stability. We find that the majority of physicians believed that the 2002 reform both provided incentives for and led to more cream skimming. In 2016, however there is less consensus among physicians about the extent of cream skimming. Looking at different types of physicians we find some indications that physicians in leading positions are less likely to view cream skimming as a problem. However, there is concern that hospital management in general puts too much emphasis on economic issues.

Should I stay or should I go? The role of leadership and organisational context for hospital physicians' intention to leave their current job.

BACKGROUND: Physician turnover is a concern in many health care systems globally. A better understanding of physicians' reasons for leaving their job may inform organisational policies to retain key personnel. The aim of this study was to investigate hospital physicians' intention to leave their current job, and to investigate if such intentions are associated with how physicians assess their leaders and the organisational context. METHODS: Data was derived from a survey of 971 physicians working in public hospitals in Norway in 2016. The data was analysed using descriptive statistics and multivariate analysis. RESULTS: We found that 21.0% of all hospital physicians expressed an intention to leave their current job for another job. An additional 20.3% of physicians had not made up their mind whether to stay or leave. Physicians' perceptions of their leaders and the organisational context influence their intention to leave their hospital. Respondents who perceived their leaders as professional-supportive had a significantly lower probability of reporting an intention to leave their job. The analysis suggests that organisational context, such as department mergers, weigh in on physicians' considerations about leaving their current job. Social climate and commitment are important reasons why physician stay. CONCLUSIONS: A professional-supportive leadership style may have a positive influence on retention of physicians in public hospitals. Further research should investigate how retention of physicians is associated with performance related to organisational and leadership style.

Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System.

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)'s 2015 Health Survey (N = 2689), this study examined the public's attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities' responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of 'self-inflicted' conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial.

Is having private health insurance associated with less support for public healthcare? Evidence from the Norwegian NHS.

The purpose of this study was to investigate whether increased uptake of private health insurance (PHI) in a traditionally NHS type system is likely to affect support for the public healthcare system. Using the Norwegian healthcare system as our case, and building on a survey among 7500 citizens, with 2688 respondents, we employed multivariate analysis to uncover whether the preferences for public health services are associated with having PHI, controlling for key predictors such as socio-economic background, self-rated health and perceived health service quality, as well as age and gender. The basis for our analysis was the following two propositions related to the role of public healthcare, which the respondents were asked to score on a 5-point Likert scale (1 = "totally disagree", 5 = "totally agree"): 1) "the responsibility of providing health services should mainly be public", and 2) "the activity of private commercial actors should be limited". The regression analyses showed that the willingness to increase the role of commercial private actors is positively associated with having a PHI. However, we found no relationship between holding a PHI and support for public provision of health services when other factors were controlled for.

Public evaluation of health services across 21 European countries: The role of culture.

AIMS: This work examined the role of cultural values in understanding people's satisfaction with health services across Europe. METHODS: We used multilevel linear regression analysis on the seventh round of the European Social Survey from 2014, including c. 40,000 respondents from 21 countries. Preliminary intraclass correlation analyses led us to believe that some explanations of variance in the dependent variable were to be found at the country level. In search of country level explanations, we attempted to account for the role of national culture in influencing citizens' attitudes towards health systems. This was done by using Hofstede's dimensions of power distance, individualism, masculinity and uncertainty avoidance, giving each country in the survey a mean aggregated score. RESULTS: In our first model with individual level variables, being female, having low or medium education, experiencing financial strain, and reporting poor health and unmet medical needs were negatively associated with individual satisfaction with national healthcare systems, with the latter variable showing the strongest effect. After including Hofstede's cultural dimensions in our multilevel model, we found that the power distance index variable had a negative effect on the dependent variable, significant at the 0.1 level. CONCLUSIONS: Citizens are likely to evaluate their national health system more negatively in national cultures associated with autocracy and hierarchy.

Benzodiazepine use in COPD: empirical evidence from Norway.

BACKGROUND: The common comorbidities associated with COPD include, among others, anxiety, depression, and insomnia, for which the typical treatment involves the use of benzodiazepines (BZD). However, these medicines should be used with extra caution among COPD patients, since treatment with traditional BZD may compromise respiratory function. AIMS: This study investigated the use of BZD among persons suffering from COPD by analyzing three relevant indicators: 1) the sum of defined daily doses (DDD); 2) the number of prescribers involved; and 3) the number of different types of BZD used. DATA AND METHODS: The study builds on a linkage of national prescription data and patient-administrative data, which includes all Norwegian drug prescriptions to persons hospitalized with a COPD diagnosis during 2009, amounting to a total of 5,380 observations. Regression techniques were used to identify the patients and the clinical characteristics associated with BZD use. RESULTS: Of the 5,380 COPD patients treated in hospital during 2009, 3,707 (69%) were dispensed BZD during the following 12 months. Moreover, they were dispensed on average 197.08 DDD, had 1.22 prescribers, and used 0.98 types of BZD during the year. Women are more likely to use BZD for all levels of BZD use. Overnight planned care not only increases the risk of BZD use (DDD), but also the number of prescribers and the types of BZD in use. CONCLUSION: In light of the high levels of BZD prescription found in this study, especially among women, it is recommended that general practitioners, hospital specialists, and others treating COPD patients should aim to acquire a complete picture of their patients' BZD medication before more is prescribed in order to keep the use to a minimum.

The geography of chronic obstructive pulmonary disease: a population-based study of Norway.

Research on chronic obstructive pulmonary disease (COPD) that includes geographic information is important in order to improve care and appropriate allocation of resources to patients suffering from COPD. The purpose of this study is to investigate the geography of COPD and factors associated with the spatial patterns of COPD prevalence. Particular emphasis is put on the role of the local socioeconomic environment. Utilising information from the Norwegian Prescription Database on all lung medication prescribed in 2009 we identified 62,882 persons with COPD in the Norwegian population. Patterns of spatial clustering in the prevalence of COPD are clearly evident, even when age and gender are controlled for. Gender and age are strongly related to COPD risk. Socio-economic characteristics of the community such as education and unemployment are also significantly correlated with COPD risk. People living in rural parts of the country are generally associated with less risk than people in urban settings, and in particular people living in communities with high levels of farm and fisheries employment.

Referral quality and the cooperation between hospital physicians and general practice: the role of physician and primary care factors.

AIMS: It has been shown that referral letters from GPs often are of poor quality, but research in this field is scarce, and few efforts have been made to investigate the factors that may help explain the variation in referral quality. METHODS: Combining a survey among 1298 Norwegian hospital physicians (response rate: 52%) with information on the hospitals and the communities they are serving, this study investigates how they view the general quality of patient referrals received from GPs, and the extent to which insufficient information in referrals and inappropriate referrals is considered a problem for cooperation with GPs. RESULTS: Only 15.6% of the hospital physicians perceived the quality of the referrals to be "usually good", and both lack of information in referrals and inappropriate referrals are seen as important barriers to cooperation with GPs. Of the individual factors, former GP practice is associated with a positive view on referral quality, while regular meetings between hospital physicians and GPs seem to reduce the problems of inappropriate and incomplete referrals. Furthermore, both average number of patients on GPs' lists and lack of free capacity in nursing and care institutions in the hospital catchment area was found to be negatively associated with perceived referral quality. CONCLUSIONS: There is a need to increase the knowledge on how contextual, institutional and professional factors affect coordination of care. The main contribution of this study lies in the attempt to address the macro and micro barriers of obtaining good referral care.

Hospital physicians' assessments of their interaction with GPs: the role of physician and community characteristics.

The way in which hospital physicians and general practitioners (GPs) interact has important implications for any health care system, particularly in systems relying on gatekeeping through the GPs for moderating access to hospital and specialist services. Several individual, organisational and contextual factors may serve as potential barriers or facilitators of the interaction between specialists and GPs. Using a survey among 1229 Norwegian hospital physicians the paper tests the role of physician and community factors for hospital physicians' satisfaction with their interaction with GPs, while also controlling for relevant hospital characteristics. The results indicate that the hospital physicians are only moderately satisfied with their interaction with GPs, and that there is certainly room for improvement. The multivariate analysis shows that the more satisfied the GPs are with their interaction with the hospital, the more satisfied are also the hospital physicians with their corresponding interaction with the GPs. Furthermore, a high GP coverage in the municipalities in the hospital catchment area is associated with a higher satisfaction among the hospital physicians. The results also suggest that meeting GPs face-to-face in meetings is associated with a more positive evaluation of the interaction with GPs.

Reimbursement systems, organisational forms and patient selection: evidence from day surgery in Norway.

Cream skimming can be defined as the selective treatment of patients that demand few resources while providing high economic refunds. We test whether cream skimming occurs after the introduction of DRG-based activity-based financing (ABF) in Norway in 1997 and if the problem further increased after the 2002 organizational reform when hospitals were turned into trusts. The DRG-system offers the same economic reimbursement for patients classified within day-surgical DRGs irrespective of whether the patient receives same-day treatment or in-patient care over several days. This provides potential for cream skimming and allows us to investigate cream skimming within the actual diagnoses. Patient data from the period 1999-2005 is analyzed. Waiting times are used as indicators of patient selection and analyzed as a function of severity within each diagnosis, controlling for age and gender of the patient, as well as institutional and time-dependent variables. The analysis gives some evidence of cream skimming in the first period of ABF, in particular within the lighter orthopaedic diagnoses. However, cream skimming does not increase after the 2002 organizational reform but is stable, and for some DRGs even reduced. The study indicates that cream skimming may occur if reimbursement systems are not particularly sophisticated. Softening of budget constraints after the hospital reform of 2002 may explain why cream skimming does not increase after the reform. However, further investigation into this mechanism is needed.

[The 2002 hospital reform--physicians' views]. / Sykehuslegenes syn på sykehusreformen.

BACKGROUND: The Norwegian hospital reform of 2002 aimed at improving several aspects of the health-care service, i.e. the definition of responsibility between hospitals and their owners, equality in access to hospital-based health services, the quality of medical work, organisation of hospitals and productivity. This paper describes to what extent hospital-based physicians consider these aims to have been achieved. MATERIAL AND METHOD: A postal questionnaire was disseminated to 2 500 hospital-based physicians in January 2006. The questions comprised work conditions and remuneration, organisational matters and the perceived results of the 2002 hospital reform. The respondents were asked to compare the situation in 2006 with the pre-reform situation, and to assess whether the situation was closer or further away from the aims. RESULTS: 1,298 of the doctors responded, i.e. a response rate of 53%. The average opinion was that the aims regarding organisation, access to hospital-based health services, and quality of medical work had become more distant. 38% stated that the aim to improve the quality of medical work was more distant than before the reform as opposed to 8% who perceived it as being closer. 58% of the physicians thought productivity had increased after the reform. There were some regional differences; e.g. the physicians in the southern region experienced stronger than those in the other four regions that responsibility between hospitals and hospital owners was less defined and the quality of medical work was worse than before the reform. 49% of the respondents felt that the hospital reform had mainly had a negative impact on hospitals, whereas 18% felt that the impact had been positive.

Hospital waiting time in Norway: what is the role of organizational change?

BACKGROUND: During the last five years the Norwegian hospital sector has experienced massive reorganization efforts. The aim of this study is to establish whether two such initiatives - the introduction of ring fencing of elective surgery and activity-based budgets at department level - have had any effects on one of the most profiled objectives on the health political agenda: reduction in waiting time. METHODS: The sample studied includes 41 hospitals observed at two points of time, 1999 and 2001. Waiting time is expected to be a result of imbalance between demand and supply. Measures representing the supply side (ring fencing, activity-based budgets at departmental level, physician rate, share of emergency admissions, technical efficiency, and hospital type) and the demand side (living conditions and share of persons aged 67 or older) are included in the operationalized model. The model is estimated via stepwise OLS regression. RESULTS: The results document a negative relationship between ring fencing and waiting time, with the estimated waiting time reduction amounting to 22 days. Both the demand side variables also exert significant effects on waiting time. CONCLUSION: Although information on ring fencing, living conditions, and age distribution renders possible some predictions concerning waiting time, the current research topic should be revisited when a longer time period has elapsed. When the organizational changes have become more thoroughly embedded in the hospitals, more refined conclusions regarding hospital organizations' behaviour and effects of reorganization can be drawn.

Day surgery and hospital efficiency: empirical analysis of Norwegian hospitals, 1999-2001.

Day surgery has gained increasing significance in Norwegian health care during the 1990s, and now constitutes more than 50% of all elective surgery. Although the underlying general assumption is that this mode of delivering surgery will increase the efficiency of hospitals, most former studies have focused only on the cost-efficiency for specific types of surgical operations. The present study therefore uses data from Norwegian hospitals to test whether the proposition that day surgery spells efficiency also holds true at the hospital level. Hospital efficiency is measured as the technical efficiency of hospitals. This indicator captures how efficient hospitals are in utilising their total resources, and builds on a variety of hospital inputs (inpatient care, outpatient care) and hospital outputs (physician full-time equivalents (FTEs), other labour equivalents, medical expenses). Our empirical analysis is based on a simple decision model where the hospitals maximise utility functions of income, patients and effort under the constraint of the budget and various structural characteristics. The empirical model thus controls for several other important determinants of efficiency, such as hospital budget, the outpatient revenue share, irregularly long length of stay, hospital type and the share of emergency admissions. After accounting for these variables, our results document significant effects of day surgery on technical efficiency. The results furthermore show that the positive effect of day surgery is contingent upon hospital budget, as hospitals with large budgets experience stronger efficiency effects of day surgery.