Associations between characteristics of the patients at municipal acute bed unit admission and further transfer to hospital: a prospective observational study

Facility and Regional Variations in Admission and Discharge Patterns Within Step-Up Intermediate Care: A Cross-Sectional Study of Municipal Inpatient Acute Care Services in Norway

Background

Norwegian Municipal Inpatient Acute Care (MIPAC) services were established as part of the 2012 Coordination Reform. The intention was to prevent unnecessary hospital admissions by redirecting and maintaining less urgent patients at the primary care level, which provides inpatient acute healthcare services closer to patients' home. However, the role MIPAC plays in the patient trajectory and how trajectories vary across different units and settings is less clear.

Objective

Therefore, this study aimed to (1) describe the general patient transfer trajectories for MIPAC patients and (2) examine facility and regional variations in MIPAC patients' sources of admission and discharge destinations.

Design

A cross-sectional study using aggregated register data.

Methods

The study involved 36 662 admissions across 185 MIPAC units in 2019. Descriptive statistics were used to describe patient transfer trajectories, and a random-effects multinomial logistic model was applied to assess the association between facility and regional factors and patients' admission sources and discharge destinations.

Results

The findings revealed distinct admission and discharge patterns based on facility and regional factors. Notably, intermunicipal units with 5 and more municipalities collaborating had higher relative risk ratios (RRR) for discharging to hospital (RRR = 1.50, 95%CI: 1.30-1.72) compared with independent MIPAC units. Large MIPAC units with more than 5 beds had increased relative risk ratios of patients admitted from the hospital than from home (RRR = 4.29, 95%CI: 1.56-11.78). Additionally, regional disparities existed, with units in the Central (RRR = 2.29, 95%CI: 1.56-3.38) and Western Norway health authorities (RRR:1.58, 95%CI: 1.22-2.06) displaying higher nursing home discharge rates than units in the South-Eastern Norway health authority.

Conclusions and implications

This study confirms the Norwegian MIPAC services' adherence to admission avoidance policies and identifies significant variations in service delivery across regions and facilities. The Norwegian MIPAC model also has potential to inspire other countries in developing admission avoidance services in the primary care setting.

The Causal Effect of Community Hospitals on General Hospital Admissions. Evaluation of a Natural Experiment Using Register Data

Background

To reduce overall healthcare costs, several countries have attempted to shift services from specialist to primary care. This was also the main strategy of the Coordination Reform introduced in Norway in 2012. An important part of the reform was the introduction of Municipal Acute Wards (MAWs), a type of community hospital aimed at reducing admissions to general hospitals. The main objective of this paper is to investigate whether the implementation of MAWs had a causal effect on hospital admissions.

Methods

Monthly admission rates in total and by age groups for patients admitted with acute or elective conditions at internal medicine or surgical departments were analyzed using panel data regression techniques. We identified causal effects by exploiting the sequential roll out of the MAWs within fixed effect analyses. Our data covered all municipalities from start of 2010 until the end of 2017.

Results

The sequential implementation of the MAWs started during the summer of 2012. By the beginning of 2016 close to all municipalities had an operative MAW. The introduction of MAWs significantly reduced acute hospital admissions. The effect was strongest for patients ≥80 years admitted acutely to internal medicine departments. The effects were even stronger if the MAW had a physician on site 24/7 or was located close to a local emergency center.

Conclusion

Our findings suggest that this type of intermediate care unit is a viable option to alleviate the burden on hospitals by reducing acute secondary care admission volumes.

Finding good alternatives to hospitalisation: a data register study in five municipal acute wards in Norway

BACKGROUND

In Norway, municipal acute wards (MAWs) have been implemented in primary healthcare since 2012. The MAWs were intended to offer decentralised acute medical care 24/7 for patients who otherwise would be admitted to hospital. The aim of this study was to assess whether the MAW represents the alternative to hospitalisation as intended, through 1) describing the characteristics of patients intended as candidates for MAWs by primary care physicians, 2) exploring the need for extended diagnostics prior to admission in MAWs, and 3) exploring factors associated with patients being transferred from the MAWs to hospital.

METHODS

The study was based on register data from five MAWs in Norway in the period 2014-2020.

RESULTS

In total, 16 786 admissions were included. The median age of the patients was 78 years, 60% were women, and the median length of stay was three days. Receiving oral medication (OR 1.23, 95% CI 1.09-1.40), and the MAW being located nearby the hospital (OR 2.29, 95% CI 1.92-2.72) were factors associated with patients admitted to MAW after extended diagnostics. Patients needing advanced treatment, such as oxygen therapy (OR 2.13, 95% CI 1.81-2.51), intravenous medication (OR 1.60, 95% CI 1.45-1.81), intravenous fluid therapy (OR 1.32, 95% CI 1.19-1.47) and MAWs with long travel distance from the MAW to the hospital (OR 1.46, 95% CI 1.22-1.74) had an increased odds for being transferred to hospital.

CONCLUSIONS

Our findings indicate that MAWs do not represent the alternative to hospitalisation as intended. The results show that patients receiving extended diagnostics before admission to MAW got basic treatment, while patients in need of advanced medical treatment were transferred to hospital from a MAW. This indicates that there is still a potential to develop MAWs in order to fulfil the intended health service level.

Evaluation of the Overall Accuracy of the Combined Early Warning Scoring Systems in the Prediction of In-Hospital Mortality

Introduction Deterioration of clinical condition of in-hospital patients further leads to intensive care unit (ICU) transfer or death which can be reduced by the use of prediction tools. The early warning scoring (EWS) system is a prediction tool used in monitoring medical patients in hospitals, hospital staying length, and inpatient mortality. The present study evaluated four different EWS systems for the prediction of patient survival. Method The present prospective observational study has analyzed 217 patients visiting the emergency department from November 2016 to November 2018, followed by demographic and clinical data collection. Modified Early Warning Score (MEWS), Triage Early Warning Score (TEWS), Leed's Early Warning Score (LEWS), and patient-at-risk scores (PARS) were assigned based upon body temperature, consciousness level, heart rate, blood pressure, respiratory rate, mobility, etc. Data was analyzed with the help of R 4.0.4 (R Foundation, Vienna, Austria) and Microsoft Excel (Microsoft, Redmond, Washington). Results Out of these 217 patients, 205 got shifted to a ward, and 12 died, amongst which the majority belonged to the 31-40 age group. Among patients admitted to ICU had a MEWS greater than 3, TEWS within the range 0 to 2 and 3 to 5, LEWS greater than 7, and PARS greater than 5 on the initial days of admission. The patients who died and those who were shifted to the ward showed significant differences in EWS. A significant association was observed between all the EWS and patient outcomes (p<0.001). Conclusion MEWS, TEWS, LEWS, and PARS were effective in the prediction of inpatient mortality as well as admission to the ICU. With the increase in the EWS, there was an increase in the duration of ICU stay and a decrease in chances of survival.

What if something happens tonight? A qualitative study of primary care physicians' perspectives on an alternative to hospital admittance

BACKGROUND

Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians' (PCPs') perspectives on admission to a MAW as an alternative to hospitalisation.

METHODS

The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach.

RESULTS

The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients' condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients' and relatives' participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients' wishes conflicted with what PCPs considered professionally sound.

CONCLUSIONS

The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.