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1.
BMC Health Serv Res ; 21(1): 884, 2021 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-34454494

RESUMO

BACKGROUND: To provide value-based care for patients with multi-morbidity, innovative integrated care programmes and comprehensive evaluations of such programmes are required. In Norway, a new programme called "Holistic Continuity of Patient Care" (HCPC) addresses the issue of multi-morbidity by providing integrated care within learning networks for frail elderly patients who receive municipal home care services or a short-term stay in a nursing home. This study conducts a multi-criteria decision analysis (MCDA) to evaluate whether the HCPC programme performs better on a large set of outcomes corresponding to the 'triple aim' compared to usual care. METHODS: Prospective longitudinal survey data were collected at baseline and follow-up after 6-months. The assessment of HCPC was implemented by a novel MCDA framework. The relative weights of importance of the outcomes used in the MCDA were obtained from a discrete choice experiment among five different groups of stakeholders. The performance score was estimated using a quasi-experimental design and linear mixed methods. Performance scores were standardized and multiplied by their weights of importance to obtain the overall MCDA value by stakeholder group. RESULTS: At baseline in the HCPC and usual care groups, respectively, 120 and 89 patients responded, of whom 87 and 41 responded at follow-up. The average age at baseline was 80.0 years for HCPC and 83.6 for usual care. Matching reduced the standardized differences between the groups for patient background characteristics and outcome variables. The MCDA results indicated that HCPC was preferred to usual care irrespective of stakeholders. The better performance of HCPC was mostly driven by improvements in enjoyment of life, psychological well-being, and social relationships and participation. Results were consistent with sensitivity analyses using Monte Carlo simulation. CONCLUSION: Frail elderly with multi-morbidity represent complex health problems at large costs for society in terms of health- and social care. This study is a novel contribution to assessing and understanding HCPC programme performance respecting the multi-dimensionality of desired outcomes. Integrated care programmes like HCPC may improve well-being of patients, be cost-saving, and contribute to the pursuit of evidence based gradual reforms in the care of frail elderly.


Assuntos
Prestação Integrada de Cuidados de Saúde , Idoso Fragilizado , Idoso , Técnicas de Apoio para a Decisão , Humanos , Noruega , Estudos Prospectivos
2.
BMC Health Serv Res ; 21(1): 697, 2021 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-34266438

RESUMO

BACKGROUND: Depression is highly prevalent, but knowledge is scarce as to whether increased public awareness and strengthened government focus on mental health have changed how general practitioners (GPs) help their depressed patients. This study aimed to examine national time trends in GP depression care and whether trends varied regarding patient gender, age, and comorbidity. METHODS: Nationwide registry-based cohort study, Norway. The study population comprised all residents aged 20 years or older with new depression diagnoses recorded in general practice, 2009-2015. We linked reimbursement claims data from all consultations in general practice for depression with information on demographics and antidepressant medication. The outcome was type(s) of GP depression care during 12 months from the date of diagnosis: (long) consultation, talking therapy, antidepressant drug treatment, sickness absence certification, and referral to secondary mental health care. Covariates were patient gender, age, and comorbidity. The data are presented as frequencies and tested with generalized linear models. RESULTS: We included 365,947 new depression diagnoses. Mean patient age was 44 years (SD = 16), 61.9 % were women, 41.2 % had comorbidity. From 2009 to 2015, proportions of patients receiving talking therapy (42.3-63.4 %), long consultations (56.4-71.8 %), and referral to secondary care (16.6-21.6 %) increased, while those receiving drug treatment (31.3-25.9 %) and sick-listing (58.1-50 %) decreased. The trends were different for gender (women had a greater increase in talking therapy and a smaller decrease in sick-listing, compared to men), age (working-aged patients had a smaller increase in talking therapy, a greater increase in long consultations, and a smaller decrease in antidepressant drug use, compared to older patients) and comorbidity (patients with mental comorbidity had a smaller increase in talking therapy and a greater increase in long consultations, compared to those with no comorbidity and somatic comorbidity). CONCLUSIONS: The observed time trends in GP depression care towards increased provision of psychological treatment and less drug treatment and sick-listing were in the desired direction according to Norwegian health care policy. However, the large and persistent differences in treatment rates between working-aged and older patients needs further investigation.


Assuntos
Medicina Geral , Clínicos Gerais , Adulto , Estudos de Coortes , Depressão/diagnóstico , Depressão/tratamento farmacológico , Depressão/epidemiologia , Feminino , Humanos , Masculino , Noruega/epidemiologia , Encaminhamento e Consulta , Sistema de Registros
3.
Fam Pract ; 2021 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-34263906

RESUMO

BACKGROUND: When patients with gastroenteritis (GE) seek health care, they are generally managed in primary care. Little is known about the use of antibiotic treatment in these cases. OBJECTIVE: The aim of this study was to investigate time trends and patient characteristics associated with antibiotic treatment for GE in Norwegian primary care in a 10-year period. METHODS: We linked data from two nationwide registries, reimbursement claims data from Norwegian primary care (the KUHR database) and The Norwegian Prescription Database, for the period 2006-15. GE consultations were extracted, and courses of systemic antibiotics dispensed within 1 day were included for further analyses. RESULTS: Antibiotic treatment was linked to 1.8% (n = 23 663) of the 1 279 867 consultations for GE in Norwegian primary care in the period 2006-15. The proportion of GE consultations with antibiotic treatment increased from 1.4% in 2006 to 2.2% in 2012 and then decreased to 1.8% in 2015. Fluoroquinolones (28.9%) and metronidazole (26.8%) were most frequently used. Whereas the number of fluoroquinolones courses decreased after 2012, the number of metronidazole courses continued to increase until year 2015. The antibiotic treatment proportion of GE consultations was lowest in young children and increased with increasing age. CONCLUSION: Antibiotic treatment is infrequently used in GE consultations in Norwegian primary care. Although there was an overall increase in use during the study period, we observed a reduction in overall use after year 2012. Young children were treated with antibiotics in GE consultations less frequent than older patients.

4.
BMC Fam Pract ; 22(1): 127, 2021 06 24.
Artigo em Inglês | MEDLINE | ID: mdl-34167484

RESUMO

BACKGROUND: Extensive use of antibiotics and the resulting emergence of antimicrobial resistance is a major health concern globally. In Norway, 82% of antibiotics is prescribed in primary care and one in four prescriptions are issued for the treatment of urinary tract infections (UTI). The aim of this study was to investigate time trends in antibiotic treatment following a consultation for UTI in primary care. METHODS: For the period 2006-2015 we linked data from the Norwegian Registry for Control and Payment of Health Reimbursements on all patient consultations for cystitis and pyelonephritis in general practice and out-of-hours (OOH) services, and data from the Norwegian Prescription Database on all dispensed prescriptions of antibiotics. RESULTS: Altogether 2,426,643 consultations by attendance for UTI took place in the study period, of these 94.5% for cystitis and 5.5% for pyelonephritis. Of all UTI consultations, 79.4% were conducted in general practice and 20.6% in OOH services. From 2006 to 2015, annual numbers of cystitis and pyelonephritis consultations increased by 33.9 and 14.0%, respectively. The proportion of UTI consultations resulting in an antibiotic prescription increased from 36.6 to 65.7% for cystitis, and from 35.3 to 50.7% for pyelonephritis. These observed changes occurred gradually over the years. Cystitis was mainly treated with pivmecillinam (53.9%), followed by trimethoprim (20.8%). For pyelonephritis, pivmecillinam was most frequently used (43.0%), followed by ciprofloxacin (20.5%) and sulfamethoxazole-trimethoprim (16.3%). For cystitis, the use of pivmecillinam increased the most during the study period (from 46.1 to 56.6%), and for pyelonephritis, the use of sulfamethoxazole-trimethoprim (from 11.4 to 25.5%) followed by ciprofloxacin (from 18.2 to 23.1%). CONCLUSIONS: During the 10-year study period there was a considerable increase in the proportion of UTI consultations resulting in antibiotic treatment. Cystitis was most often treated with pivmecillinam, and this proportion increased during the study period. Treatment of pyelonephritis was characterized by more use of broader-spectrum antibiotics, use of both sulfamethoxazole-trimethoprim and ciprofloxacin increased during the study period. These trends, indicative of enduring changes in consultation and treatment patterns for UTIs, will have implications for future antibiotic stewardship measures and policy.


Assuntos
Infecções Urinárias , Antibacterianos/uso terapêutico , Humanos , Atenção Primária à Saúde , Encaminhamento e Consulta , Sistema de Registros , Infecções Urinárias/tratamento farmacológico , Infecções Urinárias/epidemiologia
5.
Scand J Prim Health Care ; 39(2): 174-183, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34180334

RESUMO

INTRODUCTION: Quality improvement (QI) clusters have been established in many countries to improve healthcare using the Breakthrough Series' collaboration model. We investigated the effect of a novel QI approach based on this model of performed medication reviews and drug prescription in a Norwegian municipality. METHODS: All 27 General Practitioners (GPs) in a mid-size Norwegian municipality were invited to join the intervention, consisting of three peer group meetings during a period of 7-8 months. Participants learned practical QI skills by planning and following up QI projects within drug prescription practice. Evaluation forms were used to assess participants' self-rated improvement, reported medication review reimbursement codes (MRRCs) were used as a process measure, and defined daily doses (DDDs) of potentially inappropriate drugs (PIDs) dispensed to patients aged 65 years or older were used as outcome measures. RESULTS: Of the invited GPs, 25 completed the intervention. Of these, 76% self-reported improved QI skills and 67% reported improved drug prescription practices. Statistical process control revealed a non-random increase in the number of MRRCs lasting at least 7 months after intervention end. Compared with national average data, we found a significant reduction in dispensed DDDs in the intervention municipality for benzodiazepine derivates, benzodiazepine-related drugs, drugs for urinary frequency and incontinence and non-steroid anti-inflammatory and antirheumatic medications. CONCLUSION: Intervention increased the frequency of medication reviews, resulting in fewer potentially inappropriate prescriptions. Moreover, there was self-reported improvement in QI skills in general, which may affect other practice areas as well. Intervention required relatively little absence from clinical practice compared with more traditional QI interventions and could, therefore, be easier to implement.KEY POINTThe current study investigated to what extent a novel model based on the Breakthrough Series' collaborative model affects GP improvement skills in general practice and changes their drug prescription.KEY FINDINGSMost participants reported better improvement skills and improved prescription practice.The number of dispensed potentially inappropriate drugs decreased significantly in the intervention municipality compared with the national average.The model seemed to lead to sustained changes after the end of the intervention.


Assuntos
Medicina Geral , Clínicos Gerais , Prescrições de Medicamentos , Medicina de Família e Comunidade , Humanos , Melhoria de Qualidade
6.
Soc Sci Med ; 277: 113728, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33878666

RESUMO

This paper provides a deeper understanding of the mechanisms underlying implementation strategies for integrated care. As part of the SELFIE project, 17 integrated care programmes addressing multi-morbidity from eight European countries were selected and studied. Data was extracted from 'thick descriptions' of the 17 programmes and analysed both inductively and deductively using implementation theory. The following ten mechanisms for successful implementation of integrated care were identified. With regards to service delivery, successful implementers (1) commonly adopted an incremental growth model rather than a disruptive innovation approach, and found (2) a balance between flexibility and formal structures of integration. For leadership & governance, they (3) applied collaborative governance by engaging all stakeholders, and (4) distributed leadership throughout all levels of the system. For the workforce, these implementers (5) were able to build a multidisciplinary team culture with mutual recognition of each other's roles, and (6) stimulated the development of new roles and competencies for integrated care. With respect to financing, (7) secured long-term funding and innovative payments were applied as means to overcome fragmented financing of health and social care. Implementers emphasised (8) the implementation of ICT that was specifically developed to support collaboration and communication rather than administrative procedures (technology & medical devices), and (9) created feedback loops and a continuous monitoring system (information & research). The overarching mechanism was that implementers (10) engaged in alignment work across the different components and levels of the health and social care system. These evidence-based mechanisms for implementation are applicable in different local, regional and national contexts.


Assuntos
Prestação Integrada de Cuidados de Saúde , Liderança , Europa (Continente) , Humanos , Morbidade
7.
BJGP Open ; 2021 Feb 09.
Artigo em Inglês | MEDLINE | ID: mdl-33563702

RESUMO

BACKGROUND: Antidepressant drugs are often prescribed in general practice. Evidence is conflicting on how patient education influences antidepressant treatment. AIM: To investigate the association between educational attainment and drug treatment in adult patients with a new depression diagnosis, and to what extent sex and age influence the association. DESIGN & SETTING: A nationwide registry-based cohort study was undertaken in Norway from 2014-2016. METHOD: The study comprised all residents of Norway born before 1996 and alive in 2015. Information was obtained on all new depression diagnoses in general practice in 2015 (primary care database) and data on all dispensed depression medication (Norwegian Prescription Database [NorPD]) 12 months after the date of diagnosis. Independent variables were education, sex, and age. Associations with drug treatment were estimated using a Cox proportional hazard model and performed separately for sex. RESULTS: Out of 49 967 patients with new depression (61.6% women), 15 678 were dispensed drugs (30.4% women, 33.0% men). Highly educated women were less likely to receive medication (hazard ratio [HR] = 0.93; 95% confidence interval [CI] = 0.88 to 0.98) than women with low education. No such differences appeared among men. Women aged 20-29 years were more likely to be treated with drugs than those aged 30-59 years, and women aged ≥70 years were more likely to receive drugs (HR = 1.65; 95% CI = 1.54 to 1.77) than those aged 20-29 years. The pattern was similar but less pronounced for men. CONCLUSION: Educational differences in antidepressant therapy among women may reflect different treatment approaches that clinicians should be aware of to avoid unintended variation. Reasons for this variation and consequences for quality of treatment should be explored.

8.
Fam Pract ; 38(3): 238-245, 2021 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-33152060

RESUMO

BACKGROUND: Depression is more prevalent among women and people with low socio-economic status. Uncertainties exist about how general practitioner (GP) depression care varies with patients' social position. OBJECTIVE: To investigate associations between patients' gender and educational status combined and GP depression care following certification of sickness absence. METHODS: Nationwide registry-based cohort study, Norway, 2012-14. Reimbursement claims data from all consultations in general practice for depression were linked with information on socio-demographic data, social security benefits and depression medication. The study population comprised all individuals aged 25-66 years with taxable income, sick-listed with a new depression diagnosis in general practice in 2013 (n = 8857). We defined six intersectional groups by combining educational level and gender. The outcome was type of GP depression care during sick leave: follow-up consultation(s), talking therapy, medication and referral to secondary care. Associations between intersectional groups and outcome were estimated using generalized linear models. RESULTS: Among long-term absentees (17 days or more), highly educated women were less likely to receive medication compared to all other patient groups [relative risk (RR) ranging from 1.17 (95% confidence interval 1.03-1.33) to 1.49 (1.29-1.72)] and more likely to receive talking therapy than women with medium [RR = 0.90 (0.84-0.98)] or low [RR = 0.91 (0.85-0.98)] education. CONCLUSIONS: Our findings suggest that GPs provide equitable depression care regarding consultations and referrals for all intersectional groups but differential drug treatment and talking therapy for highly educated women. GPs need to be aware of these variations to provide personalized care and to prevent reproducing inequity.

9.
BMC Health Serv Res ; 20(1): 1102, 2020 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-33256723

RESUMO

BACKGROUND: As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers). METHODS: Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery. RESULTS: Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery. CONCLUSIONS: We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries.


Assuntos
Cuidadores , Prestação Integrada de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Europa (Continente) , Feminino , Serviços de Saúde para Idosos , Humanos , Masculino , Apoio Social
10.
BMC Health Serv Res ; 20(1): 963, 2020 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-33081757

RESUMO

BACKGROUND: As an alternative to acute hospitalisations, all communities in Norway are required to provide inpatient care in municipal acute bed units (MAUs) for patients who can be treated at the primary care level. Patient selection is challenging, and some patients need transfer from MAUs to hospitals. The aim of this study was to examine associations between characteristics of the patient at admission to MAU and further transfer to hospital. METHODS: In a prospective observational study on all admissions to a large MAU, March 2016-August 2017, information was obtained on patient age, gender, comorbidities, drug use, reason for stay and Triage Early Warning Score (TEWS) on admission and at discharge, and length of stay. Comparison between admissions resulting in discharge to hospital, nursing home or own home were performed with chi-square and ANOVA tests. Estimated relative risks (RR) with 95% confidence interval for transfer to hospital versus being retained at primary care level was estimated for age, gender, comorbidity and TEWS in generalized linear models, crude and adjusted. RESULTS: Two thousand seven hundred forty-four admissions were included. Mean age of the patients was 69.5 years (SD 21.9), 65.2% were women. In 646 admissions (23.6%), the patients were transferred to hospital. Male gender and TEWS > 2 were associated with transfer to hospital. Most transfers to hospital occurred within 24 h, and these patients had unchanged or increasing TEWS during their stay at MAU. When transferred to hospital 41.5% of the patients had the same reason for stay as on MAU admission, 14.9% had another reason for stay, 25.2% had a medical condition outside the treatment scope of MAU, and 18.4% needed further diagnostic clarification in hospital. CONCLUSIONS: Likelihood of transfer to hospital increased with male gender and higher TEWS on admission. Main reasons for transfer to hospital were lack of improvement and identification of clinical conditions that needed hospital care. TEWS > 2 at admission should make physicians alert to the need of close monitoring for lack of improvement.


Assuntos
Hospitais Municipais/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Pacientes/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Escore de Alerta Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Noruega , Estudos Prospectivos , Fatores Sexuais , Triagem , Adulto Jovem
11.
Subst Abuse Treat Prev Policy ; 15(1): 68, 2020 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-32883319

RESUMO

BACKGROUND: Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up. METHODS: We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from "no problems" to "extreme problems"). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100). RESULTS: Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively. CONCLUSION: The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.

12.
Fam Pract ; 36(6): 771-777, 2019 11 18.
Artigo em Inglês | MEDLINE | ID: mdl-31215999

RESUMO

BACKGROUND: Depression is prevalent in general practice, but few studies have explored patient-reported depression care. AIM: To investigate patient-reported treatment received for depression and future treatment preferences among adult patients visiting their GP, and to evaluate the associations with sex, age and educational level. DESIGN AND SETTING: A cross-sectional survey was conducted in general practices in Norway from 2016 to 2017. METHODS: Altogether, 2335 consecutive patients (response rate, 89.2%) in the GPs' waiting rooms answered a questionnaire about their received depression treatment and treatment preferences in case of future depression. RESULTS: The study population (N = 2239) had a mean age of 48.6 ± 17.7 years (range 18-91), 60.1% were women. Of the 770 patients reporting to have received depression treatment, 39.1% were treated exclusively by their GP while 52.5% also were referred to a psychologist/psychiatrist. Older age was positively associated with medication and negatively associated with referrals to psychologist/psychiatrist. People with high education had lower odds for receiving medication (odds ratios [OR], 0.49; 95% confidence intervals [CI]: 0.30-0.80) compared to those with low education. If future depression, 81.6% of the respondents would discuss this with their GP, 60.9% would prefer talking therapy with their GP, 22.5% medication, and 52.9% referral to psychologist or psychiatrist. CONCLUSION: One-third of the patients attending their GPs had consulted with them at some time concerning depression the case of future depression, most patients preferred talking therapy with the GP. This finding warrants increased research focus on the GP's role in depression care.


Assuntos
Depressão/terapia , Medicina Geral/estatística & dados numéricos , Preferência do Paciente , Medidas de Resultados Relatados pelo Paciente , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Noruega , Encaminhamento e Consulta , Inquéritos e Questionários , Adulto Jovem
13.
Acta Obstet Gynecol Scand ; 98(2): 232-239, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30252134

RESUMO

INTRODUCTION: Immigrants and their offspring constitute 16.3% of the population in Norway. Knowledge about their contraceptive use is important in order to inform adequate family planning services. Prior research has shown less use of contraception among first-generation immigrants than among non-immigrant women. Our aim is to compare the use of hormonal contraceptives between immigrants and their adult daughters. MATERIAL AND METHODS: Information from the Norwegian Prescription Database on all hormonal contraceptives dispensed at all pharmacies in Norway in 2008 was merged with demographic, socioeconomic and immigration data from the National Population Register and information from the Regular General Practitioner Database and the Medical Birth Registry Norway. A total of 10 451 women aged 16-30 from five countries with relatively large numbers of immigrants and adult daughters living in Norway in 2008 were included in the study. Descriptive statistics and logistic regression analyses were conducted. The main outcome measure was use of any hormonal contraceptive. RESULTS: More daughters of immigrants from Vietnam compared with immigrant women from these countries (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.8-2.8) and Poland (OR 2.3, 95% CI: 1.6-3.3) used hormonal contraceptives. However, no adjusted differences between generations were detected for immigrants from Pakistan (OR 1.2, 95% CI 1.0-1.4), Morocco (OR 1.0, 95% CI 0.7-1.4) or Chile (OR 1.3, 95% CI 0.8-1.9). CONCLUSIONS: Further research should explore the reasons for heterogeneity in use of contraception among daughters of immigrants from different origins and explore whether daughters of immigrant mothers from some areas have unmet needs of contraception.


Assuntos
Anticoncepcionais Orais Hormonais/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Emigrantes e Imigrantes/estatística & dados numéricos , Serviços de Planejamento Familiar , Saúde da Mulher , Adolescente , Adulto , Anticoncepção/métodos , Comportamento Contraceptivo/estatística & dados numéricos , Bases de Dados Factuais , Serviços de Planejamento Familiar/métodos , Serviços de Planejamento Familiar/estatística & dados numéricos , Feminino , Humanos , Mães , Noruega/epidemiologia , Núcleo Familiar , Avaliação de Resultados em Cuidados de Saúde , Saúde da Mulher/etnologia , Saúde da Mulher/estatística & dados numéricos
14.
Scand J Prim Health Care ; 36(4): 390-396, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30289320

RESUMO

OBJECTIVE: To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions. DESIGN: Observational study. SETTING: A two-bed municipal acute bed unit. SUBJECTS: All patients admitted to the unit between 2013 and 2016. MAIN OUTCOME MEASURES: Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate. RESULTS: Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20-1.71, adjusted for age and sex). CONCLUSION: Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level. Key Points Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed: • Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards. • Most patients were old and had complex health problems. • Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level.


Assuntos
Hospitais Municipais/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Ocupação de Leitos/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Noruega , Serviços de Saúde Rural/organização & administração , Adulto Jovem
16.
Res Social Adm Pharm ; 14(6): 612-616, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28733142

RESUMO

Drug treatment is often an essential part in treatment and prevention of diseases in older people, but there is much concern about inappropriate medication use. This paper aims to describe the complexity of medication safety issues and clinical judgments when optimizing prescribing in older individuals. It uses the case of Mrs. Hansen, an aged nursing home resident, to illustrate the facilitators and barriers of this process. With decreasing life expectancy, medication use should shift from cure to care, focusing on symptomatic treatment to increase the patient's well-being. In Mrs. Hansen's case, the number of (potentially) dangerous medications were reduced, and non-pharmacological alternatives were considered. There were some medicines added, as underprescribing can also be a problem in older people. Deprescribing long-standing treatment can be interpreted by the patient and family as "giving up hope". More clinical evidence and practical communication tools are needed to guide deprescribing decisions, taking medical and patient-centered priorities into account. Studies evaluating such interventions should select outcome measures that are particularly relevant for frail old individuals.


Assuntos
Desprescrições , Idoso Fragilizado , Idoso de 80 Anos ou mais , Feminino , Humanos , Prescrição Inadequada/prevenção & controle , Reconciliação de Medicamentos , Polimedicação
17.
J Pain Symptom Manage ; 55(2): 508-521.e3, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28803078

RESUMO

CONTEXT: Dying patients commonly experience potentially distressing symptoms. Palliative care guidelines recommend opioids, anticholinergics, antipsychotics, and benzodiazepines for symptom relief. OBJECTIVES: The objective of this study was to systematically review the effectiveness and safety of palliative drug treatment in the last days of life of adult patients, focusing on the management of pain, dyspnea, anxiety, restlessness, and death rattle. METHODS: A systematic search of the literature was published before December 2016 in PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Cochrane, ClinicalTrials.gov, and SveMed+. Studies on safety or effectiveness of drug therapy in dying adults with at least one outcome on symptom control, adverse effects, or survival were included. Data for included studies were extracted. Study quality was assessed using the Effective Public Health Practice Quality assessment tool for quantitative studies. RESULTS: Of the 5940 unique titles identified, 12 studies met the inclusion criteria. Five studies assessed anticholinergics for death rattle, providing no evidence that scopolamine hydrobromide and atropine were superior to placebo. Five studies examined drugs for dyspnea, anxiety, or terminal restlessness, providing some evidence supporting the use of morphine and midazolam. Two studies examined opioids for pain, providing some support for morphine, diamorphine, and fentanyl. Eight studies included safety outcomes, revealing no important differences in adverse effects between the interventions and no evidence for midazolam shortening survival. CONCLUSION: There is a lack of evidence concerning the effectiveness and safety of palliative drug treatment in dying patients, and the reviewed evidence provides limited guidance for clinicians to assist in a distinct and significant phase of life.


Assuntos
Tratamento Farmacológico , Cuidados Paliativos , Assistência Terminal , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Humanos
18.
Scand J Prim Health Care ; 35(2): 137-142, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28587558

RESUMO

OBJECTIVE: The Coordination reform was implemented in Norway from 2012, aiming at seamless patient trajectories. All municipalities are required to establish emergency care beds (MEBs) to avoid unnecessary hospital admissions. We aimed to examine occupancy rate, patient characteristics, diagnoses and discharge level of municipal care in a small MEB unit. DESIGN: Cross-sectional, observational study. SETTING: A two-bed emergency care unit. SUBJECTS: All patients admitted to the unit during one year. MAIN OUTCOME MEASURES: Patients' age and gender, comorbidity, main diagnoses and municipal care level on admission and discharge, diagnostic and therapeutic initiatives, occupancy rate. RESULTS: Sixty admissions were registered, with total bed occupancy 194 days, and an occupancy rate of 0.27. The patients (median age 83 years, 57% women) had mostly infections, musculoskeletal symptoms or undefined conditions. Some 48% of the stays exceeded three days and 43% of the patients were subsequently transferred to nursing homes or hospitals. CONCLUSION: Occupancy rate was low. Patient selection was not according to national standards, and stays were longer. Many patients were transferred to nursing homes, indicating that the unit was an intermediate pathway or a short cut to institutional care. It is unclear whether the unit avoided hospital admissions.


Assuntos
Ocupação de Leitos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Estudos Transversais , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Noruega , Seleção de Pacientes , Transferência de Pacientes/estatística & dados numéricos
19.
J Am Med Dir Assoc ; 18(8): 713-718, 2017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28465128

RESUMO

OBJECTIVES: Working conditions in nursing homes (NHs) may hamper teamwork in providing quality end-of-life (EOL) care, especially the participation of NH physicians. Dutch NH physicians are specialists or trainees in elderly care medicine with NHs as the main workplace, whereas in Norway, family physicians usually work part time in NHs. Thus, we aimed at assessing and comparing NH physicians' perspectives on barriers and strategies for providing EOL care in NHs in Norway and in The Netherlands. DESIGN: A cross-sectional study using an electronic questionnaire was conducted in 2015. SETTING AND PARTICIPANTS: All NH physicians in Norway (approximately 1200-1300) were invited to participate; 435 participated (response rate approximately 35%). Of the total 1664 members of the Dutch association of elderly care physicians approached, 244 participated (response rate 15%). MEASUREMENTS: We explored NH physicians' perceptions of organizational, educational, financial, legal, and personal prerequisites for quality EOL care. Differences between the countries were compared using χ2 test and t-test. RESULTS: Most respondents in both countries reported inadequate staffing, lack of skills among nursing personnel, and heavy time commitment for physicians as important barriers; this was more pronounced among Dutch respondents. Approximately 30% of the respondents in both countries reported their own lack of interest in EOL care as an important barrier. Suggested improvement strategies were routines for involvement of patients' family, pain- and symptom assessment protocols, EOL care guidelines, routines for advance care planning, and education in EOL care for physicians and nursing staff. CONCLUSIONS: Inadequate staffing levels, as well as lack of competence, time, and interest emerge as important barriers to quality EOL care according to Dutch and Norwegian NH physicians. Their perspectives were mostly similar, despite large educational and organizational differences. Key strategies for improving EOL care in their facilities comprise education and incorporating available palliative care tools and systems.


Assuntos
Casas de Saúde , Médicos/psicologia , Desenvolvimento de Programas , Assistência Terminal/organização & administração , Adulto , Estudos Transversais , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Noruega , Assistência Terminal/normas
20.
BMC Med Educ ; 17(1): 27, 2017 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-28143600

RESUMO

BACKGROUND: Doctors often find dialogues about death difficult. In Norway, 45% of deaths take place in nursing homes. Newly qualified medical doctors serve as house officers in nursing homes during internship. Little is known about how nursing homes can become useful sites for learning about end-of-life care. The aim of this study was to explore newly qualified doctors' learning experiences with end-of-life care in nursing homes, especially focusing on dialogues about death. METHODS: House officers in nursing homes (n = 16) participated in three focus group interviews. Interviews were audiotaped and transcribed verbatim. Data were analysed with systematic text condensation. Lave & Wenger's theory about situated learning was used to support interpretations, focusing on how the newly qualified doctors gained knowledge of end-of-life care through participation in the nursing home's community of practice. RESULTS: Newly qualified doctors explained how nursing home staff's attitudes taught them how calmness and acceptance could be more appropriate than heroic action when death was imminent. Shifting focus from disease treatment to symptom relief was demanding, yet participants comprehended situations where death could even be welcomed. Through challenging dialogues dealing with family members' hope and trust, they learnt how to adjust words and decisions according to family and patient's life story. Interdisciplinary role models helped them balance uncertainty and competence in the intermediate position of being in charge while also needing surveillance. CONCLUSIONS: There is a considerable potential for training doctors in EOL care in nursing homes, which can be developed and integrated in medical education. This practice based learning arena offers newly qualified doctors close interaction with patients, relatives and nurses, teaching them to perform difficult dialogues, individualize medical decisions and balance their professional role in an interdisciplinary setting.


Assuntos
Atitude Frente a Morte , Internato e Residência/organização & administração , Casas de Saúde/organização & administração , Cuidados Paliativos/psicologia , Médicos/psicologia , Aprendizagem Baseada em Problemas/métodos , Assistência Terminal/psicologia , Adulto , Educação de Pós-Graduação em Medicina/métodos , Educação de Pós-Graduação em Medicina/organização & administração , Feminino , Grupos Focais , Humanos , Internato e Residência/métodos , Masculino , Noruega , Cuidados Paliativos/métodos , Relações Médico-Paciente , Relações Profissional-Família , Pesquisa Qualitativa , Assistência Terminal/métodos , Recursos Humanos
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