The chronically ill in the labour market - are they hierarchically sorted by education?

BACKGROUND: The chronically ill as a group has on average lower probability of employment compared to the general population, a situation that has persisted over time in many countries. Previous studies have shown that the prevalence of chronic diseases is higher among those with lower levels of education. We aim to quantify the double burden of low education and chronic illness comparing the differential probabilities of employment between the chronically ill with lower, medium, and high levels of education and how their employment rates develop over time. METHODS: Using merged Norwegian administrative data over a 11-year period (2008-2018), our estimations are based on multivariable regression with labour market and time fixed effects. To reduce bias due to patients' heterogeneity, we included a series of covariates that may influence the association between labour market participation and level of education. To explicitly explore the 'shielding effect' of education over time, the models include the interaction effects between chronic illness and level of education and year. RESULTS: The employment probabilities are highest for the high educated and lowest for chronically ill individuals with lower education, as expected. The differences between educational groups are changing over time, though, driven by a revealing development among the lower-educated chronically ill. That group has a significant reduction in employment probabilities both in absolute terms and relative to the other groups. The mean predicted employment probabilities for the high educated chronic patient is not changing over time indicating that the high educated as a group is able to maintain labour market participation over time. Additionally, we find remarkable differences in employment probabilities depending on diagnoses. CONCLUSION: For the chronically ill as a group, a high level of education seems to "shield" against labour market consequences. The magnitude of the shielding effect is increasing over time leaving chronically ill individuals with lower education behind. However, the shielding effect varies in size between types of chronic diseases. While musculoskeletal, cardiovascular and partly cancer patients are "sorted" hierarchically according to level of education, diabetes, respiratory and mental patients are not.

Feedback System Analysis of a Multicomponent Intervention on Dyads of Home-Dwelling Persons With Dementia and Their Caregivers: Results From the LIVE@Home.Path Trial.

Background and Objectives: Proper symptom management, informal caregiver support, and service innovation are required to reduce dementia care burden. The objective of this study is to investigate the effect of the multicomponent LIVE (Learning, Innovation, Volunteering, Empowerment) intervention on caregiver experience of the self-perceived care situation, coordinator performance, and informal care time. Research Design and Methods: We conducted a 24-month multicomponent, stepped-wedge randomized control trial including dyads of people ≥65 years with mild-to-moderate dementia with minimum weekly contact with their informal caregivers in Norway. The intervention was implemented by municipal coordinators over a 6-month period. This study investigates the first 6-month period (September 2019-March 2020) of the trial, due to the coronavirus disease 2019 (COVID-19) pandemic. Primary outcomes are changes in provision of informal care time assessed by Resource Utilization in Dementia Care (RUD) and informal caregiver experience assessed by the Clinical Global Impression of Change (CGIC). We use logistic regression and feedback system analysis to assess the reach of the multicomponent intervention. Results: A total of 280 dyads were included at baseline, mean age of the person with dementia was 81.8 years, and 62.5% were female. After 6 months, the feedback system analysis reveals that the caregivers randomized to the intervention period reported improved caregiver situation (CGIG-T: intervention 0.63 (SD 2.4) vs control -0.43 (SD 1.7), p < .01), even though informal care time for activities of daily living was not reduced (p = .31). Informal caregivers registered a positive change for the Learning, Innovation, and Empowerment components, while no change was found for Volunteer support. Discussion and Implications: Findings illustrate the usefulness of dementia care coordinators that provide regular follow-up. We also show that complex intervention studies benefit from applying feedback system analysis. Meeting the needs of persons with dementia and their caregivers is a complex process that requires coordinated input from health services and user communities. Clinical Trial Registration Number: NCT04043364.

Worker and workplace determinants of employment exit: a register study.

BACKGROUND: Workers with chronic illness are in higher risk of unemployment. This article investigated the worker and workplace characteristics associated with labour market inclusion for workers with a diagnosed chronic illness. METHODS: Linked employer-employee register data covering all Norwegian employers and employees each month from February 2015 to December 2019 were merged with patient data from specialist healthcare (136 196 observations (job spells); 70 923 individual workers). Survival analysis was used to estimate the risk of employment exit, with age, gender, chronic illness, full-time/part-time employment, skill level, marital status, children in household, branch, share of chronically ill workers, firm size and unemployment rate as covariates. RESULTS: 85% of the study population was employed in December 2019; 58% remain employed throughout the follow-up period. Mental illness, male gender, young age, part-time employment and lower skill levels were the worker-level predictors of labour market exit. Employments in secondary industries, in firms with high shares of chronically ill workers and, to some extent, in larger firms were the significant workplace-level determinants. CONCLUSION: Only a minority of our sample of workers with chronic illness experienced labour market exclusion. Targeted measures should be considered towards workers with poor mental health and/or low formal skills. Chronically ill workers within public administration have the best labour market prospects, while workplaces within the education branch have an unfulfilled potential.

Acute management of fractures in primary care - a cost minimisation analysis.

BACKGROUND: In Norway, primary healthcare has first-line responsibility for all medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care in hospitals. However, the cooperating municipalities of Bykle and Valle have X-ray facilities and handle minor fractures locally. The aim of this study was to estimate the costs of X-ray diagnosis and initial treatment of fractures at the local primary care centre compared with initial transport and treatment in hospital. METHODS: We conducted a cost minimisation analysis by comparing expected costs of initial examination with X-ray and treatment of patients with fractures or suspected fractures at two possible sites, in the local municipality or at the hospital. A cost minimisation analysis is an economic evaluation based on the assumption that the outcomes of the two treatment procedure regimens are equal. Costs were estimated in Euros (EUR) using 2021 mean exchange rates. RESULTS: In 2019, we identified a total of 403 patients with suspected fractures in the two municipalities. Among these, 12 patients bypassed the primary care system as they needed urgent hospital care. A total of 391 injured patients were assessed with X-ray at the primary health care centres, 382 received their initial treatment there, and nine were referred to hospital. In an alternative hospital model, without X-ray and treatment possibilities in the municipality, the 382 patients would have been sent directly to hospital for radiological imaging and treatment. The total cost was estimated at EUR 367,756 in the hospital model and at EUR 69,835 in the primary care model, a cost saving of EUR 297,921. CONCLUSION: Based on cost minimisation analysis, this study found that radiological diagnosis of suspected fractures and initial treatment of uncomplicated fractures in primary care cost substantially less than transport to and treatment in hospital.

Promoting labour market inclusion of the chronically ill: a scoping review of Scandinavian countries' efforts.

OBJECTIVES: This article is a scoping review of efforts in labour market inclusion of the chronically ill in the Scandinavian countries, a research area that has received much political as well as research attention in recent years. The aim of the review was to identify promising strategies and the need for further research. METHODS: Six electronic databases were searched for literature published between 2015 and 2020. We included peer-reviewed articles that studied the effect of measures, aimed at the workplace or at the individual, that are intended to increase participation. Our search resulted in 2718 articles; our screening procedures resulted in 47 included articles. RESULTS: Among the included studies, musculoskeletal problems (17 articles) and mental health problems (29 articles) were the most frequent chronic conditions. Multimodal occupational rehabilitation programmes directed towards the individual employee were the most frequent interventions (30 articles). Return to work (24 articles) and sickness absence (12 articles) were the most common outcomes. About half (25 articles) of the included studies reported a positive impact of the intervention on work inclusion of the chronically ill. CONCLUSIONS: Our review found little evidence of how government programmes directed towards the supply side of the labour market succeed in including the chronically ill. Our review further indicated that multidisciplinary workplace interventions have a substantial effect. We also identified a significant lack of research on the effect of various governmental policies and programmes, including local health, work and welfare services, and limited coordination and cooperation between health and work services professions.

A cross-sector systematic review and synthesis of knowledge on telemedicine interventions in chronic wound management-Implications from a system perspective.

Based on initially identified needs for further telemedicine (TM) and chronic wound management research, the objective of this article is twofold: to conduct a systematic review of existing knowledge on TM interventions in chronic wound management-including barriers and opportunities-across the specialist and primary care sectors, and to incorporate the review findings into a system framework that can be further developed and validated through empirical data. We conclude that there is a pressing need for broader and more comprehensive empirical explorations into quality improvement and integration of TM in chronic wound management, including using system frameworks that can capture cross-sector system perspectives and associated implications. Of practical consideration, we suggest that the design and execution of TM improvement interventions and associated research projects should be conducted in close cooperation with managers and practitioners knowledgeable about barriers and opportunities that can influence the implementation of important interventions within chronic wound management.

Factors associated with formal and informal resource utilization in nursing home patients with and without dementia: cross-sectional analyses from the COSMOS trial.

OBJECTIVES: To investigate the association between clinical, demographic, and organizational factors and formal (health professionals) and informal (relatives) resource utilization in nursing home patients with and without dementia. METHODS: Baseline data from the multicomponent cluster randomized control COSMOS trial including 33 Norwegian nursing homes and 723 residents with and without dementia. Nursing home staff (n = 117) participated as proxy raters to approximate formal and informal resource use in daily care. MEASUREMENTS: The primary outcome was the Resource Utilization in Dementia - Formal Care scale to assess formal and informal care time in hours/month regarding basic activities of daily living (ADL), instrumental ADL, and supervision. Secondary outcomes were hours/week spent on formal and informal leisure activities. Behavioral and psychological symptoms in dementia (BPSD) were assessed by the Neuropsychiatric Inventory-Nursing Home version, physical function by the Physical Self-Maintenance Scale, and psychotropic drug use by the Anatomical Therapeutic Chemical classification system. Organizational factors were ward size and staff ratio. RESULTS: Generalized linear mixed-effect models and two-part modelling revealed an association between increased formal care time and poorer physical function, higher agitation and psychotropic drug use and lower cognitive function (all p < .05). Enhanced formal leisure time was related to better ADL function (p < .05) and smaller wards (p < .05). The family related leisure time was associated with agitation, decline in ADL function, smaller wards, and better staffing ratio (all p < .05). Married patients received more informal direct care (p < .05) and leisure time (p < .05) compared to unmarried/widowed. CONCLUSION: For nursing home staff, higher agitation and psychotropic drug use, and lower cognitive function, is associated with more direct care time, whereas leisure time activities are less prioritized in people with lower physical function. Informal caregivers' engagement is encouraged by smaller nursing homes and better staff ratio. Therefore, we recommend stakeholders and healthcare professionals to consider these clinical and organizational factors to optimize treatment and leisure time activities in nursing home patients with various needs. TRIAL REGISTRATION: ClinicalTrials.gov ; NCT02238652.

The consequences of COVID-19 lockdown for formal and informal resource utilization among home-dwelling people with dementia: results from the prospective PAN.DEM study.

BACKGROUND: COVID-19 isolated home-dwelling people with dementia (PwD) from home care services, respite care, and daytime activities. We aimed to investigate the consequences of these restrictions on informal (family, friends) and formal (homecare staff) resource utilization among co-residing (e.g., spouses) and visiting caregivers (e.g., children). METHODS: 105 PwD (≥65 years old) and their caregivers were included in the prospective PANdemic in DEMentia (PAN.DEM) study, which was initiated when the ongoing stepped-wedge, cluster randomized LIVE@Home.Path trial (N = 438) was temporarily halted due to the pandemic. Primary outcome was change in resource utilization assessed by the Resource Utilization in Dementia Care (RUD) instrument in pre- (12 Dec. 2019 to 11 Mar. 2020) and during the lockdown periods (20 April 2020 to 15 May 2020). Degree of cognitive impairment was assessed by Mini-Mental Status Examination (MMSE), and physical functioning and independent living skills by Physical Self-Maintenance Scale and Lawton Instrumental Activities of Daily Living Scale. Associations between informal and formal care utilization, socio-demographics, and clinical variables were assessed by descriptive statistics and Ordinary Least Squares models (OLS). RESULTS: Mean age for PwD was 81.8 years; 61% were female; 45.6% lived alone, and the mean MMSE score was 20.8 (SD ± 3.7). PwD with co-residents (44%) were younger (78.4 years) than those who were living alone (84.5 years; P < 0.001). During the first 2 months of lockdown, PwD missed on average 20.5 h of formal care in a month (P < 0.001) leading to an approximately 100% increase in informal care, which was particularly pronounced in personal hygiene (6.9 vs. 11.4 days in a month, P < 0.001) and supervision (9.2 vs. 17.6 days in a month; P < 0.001). Visiting caregivers increased by 1.9 days (SD ± 11.5), but co-residing caregivers increased their number of days providing ADL by approximately 7 days per month (ß = 6.9; CI, 0.39-13.1, P < 0.05) after adjusting for PwD and caregiver demographics and clinical variables. Decrease in home nursing care was particularly visible for PwD living alone (- 6.1 vs. -1.3 h per month, P = 0.005). Higher cognitive function (ß = - 0.64, CI, - 1.26 - 0.02, P = 0.044) was associated with reduction in home nursing service during the lockdown. CONCLUSION: The care situation for PwD changed dramatically in the early phase of the COVID-19 pandemic, especially for those living alone who received less support from homecare services and visiting caregivers. For future crises and the forthcoming post-pandemic period, health authorities must plan better and identify and prioritize those in greatest need. TRIAL REGISTRATION: ClinicalTrials.gov ; NCT04043364 .

Which factors increase informal care hours and societal costs among caregivers of people with dementia? A systematic review of Resource Utilization in Dementia (RUD).

BACKGROUND: Nearly 19 million people across OECD countries are living with dementia, and millions of family caregivers are affected by the disease. The costs of informal care are estimated to represent 40-75% of the total dementia cost exceeding formal care time and medical costs. OBJECTIVE: To conduct a systematic review to evaluate the methodological quality and factors associated with high informal care hours per month that increase societal costs, and to identify what type of interventions may alleviate the entire burden of informal and formal caregiving. METHODS: The systematic review was registered at PROSPERO (15.12.2020). A search in Medline, Embase, PsycINFO, and web of science for observational studies, cost-effectiveness, and cost of illness (COI) analyses on resource utilization in dementia (RUD) was conducted on 1 December 2020. Our inclusion criteria included a requirement that studies had to use the original RUD, RUD-FOCA or RUD lite in terms of hours or days per month, and costs as primary or secondary outcome, OECD countries, within the last 20 years and a sample population comprising persons with dementia (PwD) ≥65 years and their caregivers. We followed the PRISMA, GRADE, PICO guidelines and Drummond criteria to assess the methodology and quality of the studies. RESULTS: Of 307 studies, 26 cross-sectional and 3 longitudinal cohort studies were included in the analyses. Two studies had a randomized controlled trial (RCT) design. The methods and cost categories in each study varied widely. Disease severity, caregiver factors, and behavioural and psychological symptoms of dementia (BPSD) were associated with high informal care hours and societal cost. One RCT found no effect of a non-pharmacological intervention on informal care hours, yet another RCT found a cost-effective impact of an in-home respite care programme reducing informal care burden and costs. CONCLUSION: The divergent use of the RUD components within included studies encourage more harmonized analyses. There are only two RCTs on RUD, one of which shows a significant treatment effect. Larger sample sizes and longer follow-up periods are required in future RCTs with dedicated focus on cost-enhancing and resource intensive factors such as disease severity and BPSD. Novel interventions must diversify between caregiver and PwD groups. PROSPERO REGISTRATION: CRD42021226388 .

LIVE@Home.Path-innovating the clinical pathway for home-dwelling people with dementia and their caregivers: study protocol for a mixed-method, stepped-wedge, randomized controlled trial.

BACKGROUND: The global health challenge of dementia is exceptional in size, cost and impact. It is the only top ten cause of death that cannot be prevented, cured or substantially slowed, leaving disease management, caregiver support and service innovation as the main targets for reduction of disease burden. Institutionalization of persons with dementia is common in western countries, despite patients preferring to live longer at home, supported by caregivers. Such complex health challenges warrant multicomponent interventions thoroughly implemented in daily clinical practice. This article describes the rationale, development, feasibility testing and implementation process of the LIVE@Home.Path trial. METHODS: The LIVE@Home.Path trial is a 2-year, multicenter, mixed-method, stepped-wedge randomized controlled trial, aiming to include 315 dyads of home-dwelling people with dementia and their caregivers, recruited from 3 municipalities in Norway. The stepped-wedge randomization implies that all dyads receive the intervention, but the timing is determined by randomization. The control group constitutes the dyads waiting for the intervention. The multicomponent intervention was developed in collaboration with user-representatives, researchers and stakeholders to meet the requirements from the national Dementia Plan 2020. During the 6-month intervention period, the participants will be allocated to a municipal coordinator, the core feature of the intervention, responsible for regular contact with the dyads to facilitate L: Learning, I: Innovation, V: Volunteering and E: Empowerment (LIVE). The primary outcome is resource utilization. This is measured by the Resource Utilization in Dementia (RUD) instrument and the Relative Stress Scale (RSS), reflecting that resource utilization is more than the actual time required for caring but also how burdensome the task is experienced by the caregiver. DISCUSSION: We expect the implementation of LIVE to lead to a pathway for dementia treatment and care which is cost-effective, compared to treatment as usual, and will support high-quality independent living, at home. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04043364. Registered on 15 March 2019.

Co-ordination of health care: the case of hospital emergency admissions.

The recognition that chronic care delivery is suboptimal has led many health authorities around the world to redesign it. In Norway, the Department of Health and Care Services implemented the Coordination Reform in January 2012. One policy instrument was to build emergency bed capacity (EBC) as an integrated part of primary care service provided by municipalities. The explicit aim was to reduce the rate of avoidable admissions to state-owned hospitals. Using five different sources of register data and a quasi-experimental framework-the "difference-in-differences" regression approach-we estimated the association between changes in EBC on changes in aggregate emergency hospital admissions for eight ambulatory care sensitive conditions (ACSC). The results show that EBC is negatively associated with changes in aggregate ACSC emergency admissions. The associations are largely consistent with alternative model specifications. We also estimated the relationship between changes in EBC on changes in each ACSC condition separately. Our results are mixed. EBC is negatively associated with emergency hospital admissions for asthma, angina and chronic obstructive pulmonary disease but not congestive heart failure and diabetes. The main implication of the study is that EBC within primary care is potentially a sensible way of redesigning chronic care.

The Ambiguous Effect of GP Competition: The Case of Hospital Admissions.

In the theoretical literature on general practitioner (GP) behaviour, one prediction is that intensified competition induces GPs to provide more services resulting in fewer hospital admissions. This potential substitution effect has drawn political attention in countries looking for measures to reduce the growth in demand for hospital care. However, intensified competition may induce GPs to secure hospital admissions a signal to attract new patients and to keep the already enlisted ones satisfied, resulting in higher admission rates at hospitals. Using both static and dynamic panel data models, we aim to enhance the understanding of whether such relations are causal. Results based on ordinary least square (OLS) models indicate that aggregate inpatient admissions are negatively associated with intensified competition both in the full sample and for the sub-sample patients aged 45 to 69, while outpatient admissions are positively associated. Fixed-effect estimations do not confirm these results though. However, estimations of dynamic models show significant negative (positive) effects of GP competition on aggregate inpatient (outpatient) admissions in the full sample and negative effects on aggregate inpatient admissions and emergency admissions for the sub-sample. Thus, intensified GP competition may reduce inpatient hospital admissions by inducing GPs to provide more services, whereas, the alternative hypothesis seems valid for outpatient admissions. © 2016 The Authors. Health Economics Published by John Wiley & Sons, Ltd.

Reablement in community-dwelling older adults: a cost-effectiveness analysis alongside a randomized controlled trial.

BACKGROUND: In the face of a growing number of older adults in the population, policy-makers in high-income countries are seeking new ways to reduce the expected growth in long-term care expenditure. Research shows that disability is an important determinant of long-term care utilization. In this context, reablement has received increased attention. Reablement is a form of home-based rehabilitation, which focuses on improving independent functioning in daily activities perceived as important by the older adult. OBJECTIVE: To evaluate the cost-effectiveness of reablement. METHODS: The economic evaluation is based on data from a randomized controlled trial in which all participants were assessed at baseline and after 3 and 9 months. The intervention group participated in reablement, while the control group received usual care. The Canadian Occupational Performance Measure (COPM) was used to measure self-perceived activity performance and satisfaction with performance. Cost data were based on daily registrations of usage of home-based care personnel during a period of 9 months. RESULTS: Reablement was found to be more cost-effective than usual care. The assessments of performance and satisfaction regarding daily activities were significantly higher in the reablement group compared with the control group and this was achieved at lower cost. Importantly too, in the post-trial period, the intervention group requested significantly fewer home visits which were, on average, of significantly shorter duration compared with the control group. Expenditure on home visits was significantly lower for the reablement group. CONCLUSIONS: Reablement is a more cost-effective intervention compared with usual care. Reablement has a potentially large effect on the demand for compensating home-based care services. Policy-makers should therefore consider implementing reablement on a larger scale.

Prioritization and the elusive effect on welfare - a Norwegian health care reform revisited.

The Faster Return to Work (FRW) scheme that Norwegian authorities implemented in 2007 is an example of a policy that builds on the human capital approach. The main idea behind the scheme is that long waiting times for hospital treatment lead to unnecessarily long periods of absence from work. To achieve a reduction in average sickness absence duration, the allocation of FRW funds and new treatment capacity is exclusively aimed at people on sick leave. Many countries have allocated funds to reduce waiting times for hospital treatment and research shows that more resources allocated to the hospital sector can reduce waiting times. Our results support this as the FRW scheme significantly reduces waiting times. However, on average the reduction in waiting times is not transformed into an equally large reduction in the sickness absence period. We find significant difference in the effects of FRW on length of sick leave between surgical and non-surgical patients though. The duration of sick leave for FRW patients undergoing surgical treatment is approximately 14 days shorter than for surgical patients on the regular waiting list. We find no significant effect of the scheme on length of sick leave for non-surgical patients. In sum, our welfare analysis indicates that prioritization of the kind that the FRW scheme represents is not as straightforward as one would expect. The FRW scheme costs more than it contributes in reduced productivity loss. We base our analyses on several different econometric methods using register data on approximately 13,500 individuals over the period 2007-2008.

Reablement in community-dwelling adults: study protocol for a randomised controlled trial.

BACKGROUND: As a result of the ageing population, there is an urgent need for innovation in community health-care in order to achieve sustainability. Reablement is implemented in primary care in some Western countries to help meet these challenges. However, evidence to support the use of such home-based rehabilitation is limited. Reablement focuses on early, time-intensive, multidisciplinary, multi-component and individualised home-based rehabilitation for older adults with functional decline. The aim of this study is to investigate the effectiveness of reablement in home-dwelling adults compared with standard treatment in relation to daily activities, physical functioning, health-related quality of life, use of health-care services, and costs. METHODS/DESIGN: The study will be a 1:1 parallel-group randomised controlled superiority trial conducted in a rural municipality in Norway. The experimental group will be offered reablement and the control group offered standard treatment. A computer-generated permuted block randomisation sequence, with randomly selected block sizes, will be used for allocation. Neither participants nor health-care providers will be blinded, however all research assistants and researchers will be blinded. The sample size will consist of 60 participants. People will be eligible if they are home-dwelling, over 18 years of age, understand Norwegian and have functional decline. The exclusion criteria will be people in need of institution-based rehabilitation or nursing home placement, and people who are terminally ill or cognitively reduced. The primary outcome will be self-perceived performance, and satisfaction with performance of daily activities, assessed with the Canadian Occupational Performance Measure. In addition, physical capacity, health-related quality of life, use of health-care services, and cost data will be collected at baseline, and after 3 and 9 months in both groups, and again after 15 months in the intervention group. Data will be analysed on an intention-to-treat basis using a linear mixed model for repeated measures. DISCUSSION: The findings will make an important contribution to evaluating cost-effective and evidence-based rehabilitation approaches for community-dwelling adults. TRIAL REGISTRATION: The trial was registered in ClinicalTrials.gov November 20, 2012, identifier: NCT02043262.

Between two beds: inappropriately delayed discharges from hospitals.

Acknowledging the necessity of a division of labour between hospitals and social care services regarding treatment and care of patients with chronic and complex conditions, is to acknowledge the potential conflict of interests between health care providers. A potentially important conflict is that hospitals prefer comparatively short length of stay (LOS) at hospital, while social care services prefer longer LOS all else equal. Furthermore, inappropriately delayed discharges from hospital, i.e. bed blocking, is costly for society. Our aim is to discuss which factors that may influence bed blocking and to quantify bed blocking costs using individual Norwegian patient data, merged with social care and hospital data. The data allow us to divide hospital LOS into length of appropriate stay (LAS) and length of delay (LOD), the bed blocking period. We find that additional resources allocated to social care services contribute to shorten LOD indicating that social care services may exploit hospital resources as a buffer for insufficient capacity. LAS increases as medical complexity increases indicating hospitals incentives to reduce LOS are softened by considerations related to patients' medical needs. Bed blocking costs constitute a relatively large share of the total costs of inpatient care.

Interdependency between social care and hospital care: the case of hospital length of stay.

BACKGROUND: Poor co-ordination and collaboration have been identified by many governments as a major and growing weakness of their health care systems. Better integrated care for the elderly individuals is one field of particular importance. In this study, we ask to what extent local authorities' social care services create cost externalities by prolonging hospital length of stay (LOS) because of inadequate service capacity and/or service quality. METHODS: The data set is constructed by merging in-patient data from the Norwegian Patient Register with Statistics Norway's local authority variables for the period from 2007 to 2009. The sample includes ∼386 000 observations of in-patients aged ≥ 67 years. Using the quantile regression (QR) technique, we analyse the impact of social care services along the entire distribution of LOS. The QR estimates are compared with ordinary least square estimates (OLS). Patient variables in the analyses include age, gender and case-mix variables. Hospital and time-fixed effects are also controlled for variables. RESULTS: More resources to the social care services give shorter LOS, and the QR analysis shows that resources matter more for patients in the long tail of the distribution compared with those in the lower quantiles. LOS is longer for patients with change of residence after discharge from hospital compared with those patients that do not change residence. CONCLUSIONS: Increased supply of social care services contributes to a reduction in aggregate societal costs of treatment and nursing of elderly patients by shortening comparatively costly hospital LOS.

Auctions vs negotiations: a study of price differentials.

Recent contributions in auction and bargaining theory suggest that a procurer should place more faith in the power of competition among alternative suppliers than in his or her own negotiating skill. Based on data from 216 contracts between procurers and suppliers of medical and surgical articles, we test whether auctions and bargaining result in significantly different prices. The main results are that auctions give 'thicker' markets compared with negotiations, as expected, but that auctions do not result in significantly lower prices compared with negotiations.

Prospective funding of general hospitals in Norway--incentives for higher production?

In Norway, a new system of Activity Based Financing (ABF) for general hospitals was introduced on a comprehensive basis in July 1997. The main purpose of the reform was to increase activity so that more patients could receive treatment more quickly without reducing the quality of care. In this paper we analyse whether the reform has had any significant effect using two different performance indicators: number of patients treated and production of DRG points (Diagnosis Related Group). We divide the hospitals into two groups: hospitals owned by counties that have adopted the ABF system, and hospitals owned by counties using other funding systems. The first group then becomes the experiment group, while the second serves as a comparison group. It is argued that fixed-effect models are suitable specifications for this evaluation study, handling selection bias and the influence of unobservable explanatory variables in a consistent manner. We find that the reform has had a significant effect on the number of patients treated and DRG points produced. The results are sensitive as to how the experiment and the comparison group are determined.

A low-key social insurance reform--effects of multidisciplinary outpatient treatment for back pain patients in Norway.

This paper estimates treatment effects for back pain patients using observational data from a low-key social insurance reform in Norway. Using a latent variable model, we estimate the average treatment effect (ATE), the average effect of treatment on the treated (TT), and the distribution of treatment effects for multidisciplinary outpatient treatment at three different locations. To estimate these treatment effects, we use a discrete-choice model with unobservables generated by a factor structure model. Distance to the nearest hospital (in kilometres) is used as an instrument in estimating the different treatment effects. We find a positive effect of treatment of around 6 percentage points on the probability of leaving the sickness benefits scheme after allowing for selection effects and full heterogeneity in treatment effects. We also find that there are sound arguments for expanding the multidisciplinary outpatient programme for treating back pain patients.