New Public Management and hospital efficiency: the case of Norwegian public hospital trusts.

New Public Management-inspired reforms in the Norwegian hospital sector have introduced several features from the private sector into a predominantly public healthcare system. Since the late 1990s, several reforms have been carried out with the intention of improving the utilization of resources. There is, however, limited knowledge about the long-term, and sector-wide effects of these reforms. In this study, using a panel data set of all public hospital trusts spanning nine years, we provide an analysis of the efficiency of hospital trusts using data envelopment analysis (DEA), as well as a Malmquist productivity index. Thereafter we use the efficiency scores as the dependent variable in a second-stage panel data regression analysis. We show that during the period between 2011 and 2019, on average, efficiency has increased over time. Further, in the second-stage analysis, we show that New Public Management features related to incentivization are associated with the level of hospital efficiency. We find no association between degree of competition and efficiency.

The effectiveness of exercise therapy and education plus cognitive behavioral therapy, alone or in combination with total knee arthroplasty in patients with knee osteoarthritis - study protocol for the MultiKnee trial.

BACKGROUND: One in five patients report chronic pain following total knee arthroplasty (TKA) and are considered non-improvers. Psychological interventions such as cognitive behavioral therapy (CBT), combined with exercise therapy and education may contribute to reduced pain an improved function both for patients with OA or after TKA surgery, but the evidence for the effectiveness of such interventions is scarce. This randomized controlled trial with three arms will compare the clinical effectiveness of patient education and exercise therapy combined with internet-delivered CBT (iCBT), evaluated either as a non-surgical treatment choice or in combination with TKA, in comparison to usual treatment with TKA in patients with knee OA who are considered candidates for TKA surgery. METHODS: The study, conducted in three orthopaedic centers in Norway will include 282 patients between ages 18 and 80, eligible for TKA. Patients will be randomized to receive the exercise therapy + iCBT, either alone or in combination with TKA, or to a control group who will undergo conventional TKA and usual care physiotherapy following surgery. The exercise therapy will include 24 one hour sessions over 12 weeks led by a physiotherapist. The iCBT program will be delivered in ten modules. The physiotherapists will receive theoretical and practical training to advise and mentor the patients during the iCBT program. The primary outcome will be change from baseline to 12 months on the pain sub-scale from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include the remaining 4 sub-scales from the KOOS (symptoms, function in daily living, function in sports and recreation, and knee-related quality of life), EQ-5D-5L, the Pain Catastrophizing Scale, the 30-s sit-to-stand test, 40-m walking test and ActiGraph activity measures. A cost-utility analysis will be performed using QALYs derived from the EQ-5D-5L and registry data. DISCUSSION: This is the first randomized controlled trial to investigate the effectiveness of exercise therapy and iCBT with or without TKA, to optimize outcomes for TKA patients. Findings from this trial will contribute to evidence-based personalized treatment recommendations for a large proportion of OA patients who currently lack an effective treatment option. TRIAL REGISTRATION: Clinicaltrials.gov : NCT03771430 . Registered: Dec 11, 2018.

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.

Factors contributing to post-stroke health care utilization and costs, secondary results from the life after stroke (LAST) study.

BACKGROUND: The result from the Life After Stroke (LAST) study showed that an 18-month follow up program as part of the primary health care, did not improve maintenance of motor function for stroke survivors. In this study we evaluated whether the follow-up program could lead to a reduction in the use of health care compared to standard care. Furthermore, we analyse to what extent differences in health care costs for stroke patients could be explained by individual need factors (such as physical disability, cognitive impairment, age, gender and marital status), and we tested whether a generic health related quality of life (HRQoL) is able to predict the utilisation of health care services for patients post-stroke as well as more disease specific indexes. METHODS: The Last study was a multicentre, pragmatic, single-blinded, randomized controlled trial. Adults (age ≥ 18 years) with first-ever or recurrent stroke, community dwelling, with modified Rankin Scale < 5. The study included 380 persons recruited 10 to 16 weeks post-stroke, randomly assigned to individualized coaching for 18 months (n = 186) or standard care (n = 194). Individual need was measured by the Motor assessment scale (MAS), Barthel Index, Hospital Anxiety and Depression Scale (HADS), modified Rankin Scale (mRS) and Gait speed. HRQoL was measured by EQ-5D-5 L. Health care costs were estimated for each person based on individual information of health care use. Multivariate regression analysis was used to analyse cost differences between the groups and the relationship between individual costs and determinants of health care utilisation. RESULTS: There were higher total costs in the intervention group. MAS, Gait speed, HADS and mRS were significant identifiers of costs post-stroke, as was EQ-5D-5 L. CONCLUSION: Long term, regular individualized coaching did not reduce health care costs compared to standard care. We found that MAS, Gait speed, HADS and mRS were significant predictors for future health care use. The generic EQ-5D-5 L performed equally well as the more detailed battery of outcome measures, suggesting that HRQoL measures may be a simple and efficient way of identifying patients in need of health care after stroke and targeting groups for interventions. TRIAL REGISTRATION: https://www.clinicaltrials.govNCT01467206. The trial was retrospectively registered after the first 6 participants were included.

Estimating the future burden of hip fractures in Norway. A NOREPOS study.

BACKGROUND: The incidence rate of hip fractures seems to be declining in many western countries. However, due to the ageing of the population, the number of fractures may still be on the rise. No papers so far have quantified the future burden of hip fractures in terms of both health loss (as measured in disability adjusted life years DALY) and costs. The purpose of this paper is to assess the future health and economic burden of hip fractures. METHODS: We collected population projections from Statistics Norway up until the year 2040. The medium projection was used for the base case analysis. Fracture rates for 2008 were estimated based on information from the Norwegian Epidemiologic Osteoporosis Studies (NOREPOS) hip fracture database (NORHip), which includes information about all hip fractures in Norway. Future fracture rate was assumed to decline by 0.7% per year in the base case. We used the same assumptions as the global burden of disease project on years of remaining life and disability weights. Cost of hip fracture was based on the published literature. In sensitivity analyses, we assessed the impact of changing underlying assumptions on demographic change, development in hip fracture rate, assumed life expectancy and choice of disability weights. RESULTS: Assuming a medium population growth and a continued decline in fracture rate, our estimates indicate that health lost to hip fractures will approximately double, from 32,850 DALYs in 2020 to 60,555 in 2040. Over the same period, costs are estimated to increase by 65%. Sensitivity analyses indicate that estimates are highly sensitive to assumptions on both population growth, fracture rate development, disability weights and assumed life expectancy. CONCLUSION: The burden of hip fractures in terms of DALYs lost and cost incurred is likely to increase even if the fracture rate continues to decline.

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.

The effect of copayments on the utilization of the GP service in Norway.

We examine the effect of copayment on the utilization of the GP service in Norway. We use a regression discontinuity design to study two key aspects of the policy. First, we examine the overall effect of copayments on total utilization of the GP service. Second, we look at how this effect varies across different patient groups according to medical necessity. Data consists of 5,5 million GP visits for youths aged 10-20 over the 6 year period 2009-2014. We find that the introduction of a co-payment leads to an overall reduction of GP visits of 10-15%. The effect is heterogeneous across patient groups. Patients with an acute condition exhibit low price sensitivity. Patients with general complaints and symptoms, chronic diseases and psychological diseases all react strongly to the copayment. The two latter groups capture patients with conditions that typically warrant medical attention. This paper thus suggests that the current flat fee copayment policy is inefficient at targeting unnecessary use of the GP service at the cost of patients with real medical concerns.

Economic incentives and diagnostic coding in a public health care system.

We analysed the association between economic incentives and diagnostic coding practice in the Norwegian public health care system. Data included 3,180,578 hospital discharges in Norway covering the period 1999-2008. For reimbursement purposes, all discharges are grouped in diagnosis-related groups (DRGs). We examined pairs of DRGs where the addition of one or more specific diagnoses places the patient in a complicated rather than an uncomplicated group, yielding higher reimbursement. The economic incentive was measured as the potential gain in income by coding a patient as complicated, and we analysed the association between this gain and the share of complicated discharges within the DRG pairs. Using multilevel linear regression modelling, we estimated both differences between hospitals for each DRG pair and changes within hospitals for each DRG pair over time. Over the whole period, a one-DRG-point difference in price was associated with an increased share of complicated discharges of 14.2 (95 % confidence interval [CI] 11.2-17.2) percentage points. However, a one-DRG-point change in prices between years was only associated with a 0.4 (95 % CI [Formula: see text] to 1.8) percentage point change of discharges into the most complicated diagnostic category. Although there was a strong increase in complicated discharges over time, this was not as closely related to price changes as expected.

Productivity growth, case mix and optimal size of hospitals. A 16-year study of the Norwegian hospital sector.

BACKGROUND AND OBJECTIVES: This paper analyses productivity growth in the Norwegian hospital sector over a period of 16 years, 1999-2014. This period was characterized by a large ownership reform with subsequent hospital reorganizations and mergers. We describe how technological change, technical productivity, scale efficiency and the estimated optimal size of hospitals have evolved during this period. MATERIAL AND METHODS: Hospital admissions were grouped into diagnosis-related groups using a fixed-grouper logic. Four composite outputs were defined and inputs were measured as operating costs. Productivity and efficiency were estimated with bootstrapped data envelopment analyses. RESULTS: Mean productivity increased by 24.6% points from 1999 to 2014, an average annual change of 1.5%. There was a substantial growth in productivity and hospital size following the ownership reform. After the reform (2003-2014), average annual growth was <0.5%. There was no evidence of technical change. Estimated optimal size was smaller than the actual size of most hospitals, yet scale efficiency was high even after hospital mergers. However, the later hospital mergers have not been followed by similar productivity growth as around time of the reform. CONCLUSIONS: This study addresses the issues of both cross-sectional and longitudinal comparability of case mix between hospitals, and thus provides a framework for future studies. The study adds to the discussion on optimal hospital size.

Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature.

BACKGROUND: Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis. METHODS: Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables. RESULTS: Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients. CONCLUSION: This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.

Factors associated with the amount of public home care received by elderly and intellectually disabled individuals in a large Norwegian municipality.

This study reports an analysis of factors associated with home care use in a setting in which long-term care services are provided within a publicly financed welfare system. We considered two groups of home care recipients: elderly individuals and intellectually disabled individuals. Routinely collected data on users of public home care in the municipality of Trondheim in October 2012, including 2493 people aged 67 years or older and 270 intellectually disabled people, were used. Multivariate regression analysis was used to analyse the relationship between the time spent in direct contact with recipients by public healthcare personnel and perceived individual determinants of home care use (i.e. physical disability, cognitive impairment, diagnoses, age and gender, as well as socioeconomic characteristics). Physical disability and cognitive impairment are routinely registered for long-term care users through a standardised instrument that is used in all Norwegian municipalities. Factor analysis was used to aggregate the individual items into composite variables that were included as need variables. Both physical disability and cognitive impairment were strong predictors of the amount of received care for both elderly and intellectually disabled individuals. Furthermore, we found a negative interaction effect between physical disability and cognitive impairment for elderly home care users. For elderly individuals, we also found significant positive associations between weekly hours of home care and having comorbidity, living alone, living in a service flat and having a safety alarm. The reduction in the amount of care for elderly individuals living with a cohabitant was substantially greater for males than for females. For intellectually disabled individuals, receiving services involuntarily due to severe behavioural problems was a strong predictor of the amount of care received. Our analysis showed that routinely collected data capture important predictors of home care use and thus facilitate both short-term budgeting and long-term planning of home care services.

A randomised controlled study of the long-term effects of exercise training on mortality in elderly people: study protocol for the Generation 100 study.

INTRODUCTION: Epidemiological studies suggest that exercise has a tremendous preventative effect on morbidity and premature death, but these findings need to be confirmed by randomised trials. Generation 100 is a randomised, controlled study where the primary aim is to evaluate the effects of 5 years of exercise training on mortality in an elderly population. METHODS AND ANALYSIS: All men and women born in the years 1936-1942 (n=6966), who were residents of Trondheim, Norway, were invited to participate. Between August 2012 and June 2013, a total of 1567 individuals (790 women) were included and randomised to either 5 years of two weekly sessions of high-intensity training (10 min warm-up followed by 4×4 min intervals at ∼90% of peak heart rate) or, moderate-intensity training (50 min of continuous work at ∼70% of peak heart rate), or to a control group that followed physical activity advice according to national recommendations. Clinical examinations, physical tests and questionnaires will be administered to all participants at baseline, and after 1, 3 and 5 years. Participants will also be followed up by linking to health registries until year 2035. ETHICS AND DISSEMINATION: The study has been conducted according to the SPIRIT statement. All participants signed a written consent form, and the study has been approved by the Regional Committee for Medical Research Ethics, Norway. Projects such as this are warranted in the literature, and we expect that data from this study will result in numerous papers published in world-leading clinical journals; we will also present the results at international and national conferences. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT01666340.

Variations in levels of care between nursing home patients in a public health care system.

BACKGROUND: Within the setting of a public health service we analyse the distribution of resources between individuals in nursing homes funded by global budgets. Three questions are pursued. Firstly, whether there are systematic variations between nursing homes in the level of care given to patients. Secondly, whether such variations can be explained by nursing home characteristics. And thirdly, how individual need-related variables are associated with differences in the level of care given. METHODS: The study included 1204 residents in 35 nursing homes and extra care sheltered housing facilities. Direct time spent with patients was recorded. In average each patient received 14.8 hours direct care each week. Multilevel regression analysis is used to analyse the relationship between individual characteristics, nursing home characteristics and time spent with patients in nursing homes. The study setting is the city of Trondheim, with a population of approximately 180 000. RESULTS: There are large variations between nursing homes in the total amount of individual care given to patients. As much as 24 percent of the variation of individual care between patients could be explained by variation between nursing homes. Adjusting for structural nursing home characteristics did not substantially reduce the variation between nursing homes. As expected a negative association was found between individual care and case-mix, implying that at nursing home level a more resource demanding case-mix is compensated by lowering the average amount of care. At individual level ADL-disability is the strongest predictor for use of resources in nursing homes. For the average user one point increase in ADL-disability increases the use of resources with 27 percent. CONCLUSION: In a financial reimbursement model for nursing homes with no adjustment for case-mix, the amount of care patients receive does not solely depend on the patients' own needs, but also on the needs of all the other residents.

Are fear avoidance beliefs associated with abdominal muscle activation outcome for patients with low back pain?

BACKGROUND AND PURPOSE: Activation of transversus abdominis and fear avoidance beliefs have both been related to low back pain (LBP). This exploratory study aims to investigate associations between fear avoidance beliefs at baseline and deep abdominal muscle activation after an 8-week period of supervised exercises for chronic LBP. METHODS: A cohort of patients with chronic non-specific LBP (N = 108) enrolled in a clinical trial was studied longitudinally. Fear avoidance beliefs for physical activity and work were measured before intervention. Activation in transversus abdominis and obliquus internus abdominis during abdominal drawing-in manoeuvre and rapid arm flexion was measured by ultrasound before and after intervention. Associations between baseline fear avoidance beliefs and deep abdominal muscle activation after exercises were analysed with multiple linear regression methods. RESULTS: High fear avoidance beliefs for physical activity (≥16 on the subscale) were negatively associated with transversus abdominis slide after the intervention period, ß = -4.92 (-8.40 to -1.45). There were no associations between fear avoidance beliefs for physical activity and abdominal muscle onset, transversus abdominis or obliquus internus contraction ratio. Fear avoidance beliefs for work were not associated with any of the muscle activation parameters. CONCLUSION: This study suggests that there is some negative association between fear avoidance beliefs for physical activity before intervention and transversus abdominis recruitment measured by lateral slide after intervention. No other significant associations between fear avoidance beliefs and abdominal muscle activation were found. We cannot exclude random findings, meaning that the results should be considered hypothesis generating for further investigations.