The Role of Chief Medical officers in making Public Health Overview Documents in Norwegian Municipalities. A qualitative Study

AIMS

To investigate how Chief Medical Officers experience their role in the municipalities´ work with making the public health overview documents, demanded by the Norwegian Public Health Act from 2012.

METHODS

A qualitative study with semi-structured focus group interviews with 21 Chief Medical Officers from 20 different municipalities in Norway. The interviews were conducted in 2017. The data were analyzed thematically.

RESULTS

The Chief Medical Officers were mainly positive to participating in making public health overview documents. They took on roles as leaders of the work, medical advisors, data collectors towards local GPs and listening post to other sectors. Organizational factors like too small positions and a lack of tradition to involve the CMO in public health work were experienced as barriers to their involvement. The collaboration with the public health coordinators was said to be rewarding, and the intersectoral process involved employees from other sectors in a new way in public health. Although there were some positive experiences, several CMOs considered the use and impact of the public health overview document as limited.

CONCLUSION

There was a large variation in the amount and the type of involvement the Chief Medical Officers had in making the public health overview documents in Norwegian municipalities. More research is needed to understand if this has any consequences for the quality of public health work in the municipalities and whether it is a sign of a changing role of the Chief Medical Officers.

Healthcare professionals' experiences of interdisciplinary collaboration in pain centres - A qualitative study

OBJECTIVES

The complexity of chronic pain requires interdisciplinary collaboration. Although this is recognisable in the framework for pain centres, few studies have investigated how interdisciplinary collaboration in pain centres is experienced by healthcare professionals, including the facilitators and barriers to interdisciplinary collaboration. The aim of the current study was therefore to investigate experiences of interdisciplinary collaboration in the treatment of patients with chronic pain among healthcare professionals in tertiary care pain centres.

METHODS

Eleven healthcare professionals, representing different healthcare disciplines from the four regional pain centres in Norway, participated in semi-structured individual interviews. The data were analysed thematically.

RESULTS

The results were categorised into three themes 'The best approach for chronic pain treatment', 'Collegial collaboration', and 'Challenges with interdisciplinary teamwork'. The informants valued the interdisciplinary work at the pain centre. They perceived it as the best approach for their patients and appreciated the support the collegial collaboration gave them as professionals. Although working together was rewarding and provided new insights, the informants also experienced the interdisciplinary teamwork as challenging, e.g., when the different professions disagreed on recommendations for further treatment or did not manage to work together as a team.

CONCLUSION

The informants found the interdisciplinary collaboration at the pain centre to provide the best treatment approach for their patients. It should be acknowledged that interdisciplinary teamwork can be challenging, and efforts should be put into establishing a good climate for collaboration and gaining knowledge about each profession's unique character and how they contribute to pain centre treatments.

The effect of using desktop VR to practice preoperative handovers with the ISBAR approach: a randomized controlled trial

AIM

The aim was to investigate whether second-year undergraduate nursing students practicing the Identification-Situation-Background-Assessment-Recommendation (ISBAR) communication approach in a desktop virtual reality (VR) application had a non-inferior learning outcome compared with the traditional paper-based method when sorting patient information correctly based on the ISBAR structure.

METHODS

A non-inferior parallel group assessor blinded randomized controlled trial, conducted in simulation sessions as part of preparation for clinical placements in March and April 2022. After a 20-minute introductory session, the participants were randomized to self-practice the ISBAR approach for 45 minutes in groups of three in either an interactive desktop VR application (intervention) or traditional paper-based (TP) simulation. The primary outcome concerned the proportion of nursing students who sorted all 11 statements of patient information in the correct ISBAR order within a time limit of 5 min. The predefined, one-sided, non-inferiority limit was 13 percentage points in favor of traditional paper-based simulation.

RESULTS

Of 210 eligible students, 175 (83%) participated and were allocated randomly to the VR (N = 87) or TP (N = 88) group. Practicing in the desktop VR application (36% of everything correct) was non-inferior to the traditional paper-based method (22% everything correct), with a difference of 14.2 percentage points (95% CI 0.7 to 27.1) in favor of VR. The VR group repeated the simulation 0.6 times more (95% CI 0.5 to 0.7). Twenty percent more (95% CI 6.9 to 31.6) of the students in the VR group reported liked how they practiced. All the other outcomes including the System Usability Scale indicated non-inferiority or were in favor of VR.

CONCLUSIONS

Self-practicing with the ISBAR approach in desktop VR was non-inferior to the traditional paper-based method and gave a superior learning outcome.

TRIAL REGISTRATION NUMBER

ISRCTN62680352 registered 30/05/2023.

Association between Johns Hopkins Adjusted Clinical Groups risk scores and self-reported outcome measures: an observational study among individuals with complex or long-term conditions in Norway

OBJECTIVE

Investigate the association between Johns Hopkins Adjusted Clinical Groups (ACG) risk scores and low scores in self-reported outcome measures (SROMs) among individuals with complex or long-term conditions.

DESIGN

Longitudinal study using five ACG risk scores based on diagnoses from general practitioner (GP) visits in 1 year and responses to a survey including three SROMs 4 months later.

SETTING

Four adjacent municipalities in Central Norway.

PARTICIPANTS

Non-institutionalised individuals ≥18 years with ≥1 diagnosis code indicating a complex or long-term condition, ≥1 visit to a GP, and who participated in the survey (n=2944).

MEASURES

Dependent variables were low scores in the three SROMs (threshold for being defined as a low score in parentheses): Patient Activation Measure (level 1-2), EQ-5D (<0.4) or self-rated health ('Poor'). Independent variables were five ACG variables.

RESULTS

The individuals with the lowest scores in the three SROMs were mostly three separate groups. The lowest Patient Activation Measure scores were associated with high scores in the ACG variables unscaled total cost predicted risk (adjusted odds ratio (adjOR) 1.80) and positive frailty flag (adjOR 1.76). The lowest EQ-5D scores were associated with high scores in the ACG variables unscaled concurrent risk (adjOR 1.60) and probability persistent high user scores (adjOR 2.83). The lowest self-rated health scores were associated with high scores in the ACG variable unscaled concurrent risk scores (adjOR 1.77), unscaled total cost predicted risk scores (adjOR 2.14) and receiving a positive frailty flag (adjOR 1.82).

CONCLUSIONS

There were associations between ACG risk scores and subsequent low SROM scores. This suggests a potential to use diagnosis-based risk stratification systems as a proxy for SROMs to identify individuals with complex or long-term conditions for person-centred healthcare intervention.

Developing a virtual reality (VR) application for practicing the ABCDE approach for systematic clinical observation

BACKGROUND

The Airways, Breathing, Circulation, Disability, Exposure (ABCDE) approach is an international approach for systematic clinical observation. It is an essential clinical skill for medical and healthcare professionals and should be practiced repeatedly. One way to do so is by using virtual reality (VR). The aim was therefore to develop a VR application to be used by inexperienced health students and professionals for self-instructed practice of systematic clinical observation using the ABCDE approach.

METHODS

An iterative human-centred approach done in three overlapping phases; deciding on the ABCDE approach, specifying the requirements, and developing the application.

RESULTS

A total of 138 persons were involved. Eight clinical observations were included in the ABCDE approach. The requirements included making it possible for inexperienced users to do self-instructed practice, a high level of immersion, and a sense of presence including mirroring the physical activities needed to do the ABCDE approach, allowing for both single and multiplayer, and automatic feedback with encouragement to repeat the training. In addition to many refinements, the testing led to the development of some new solutions. Prominent among them was to get players to understand how to use the VR hand controllers and start to interact with the VR environment and more instructions like showing videos on how to do observations. The solutions in the developed version were categorised into 15 core features like onboarding, instructions, quiz, and feedback.

CONCLUSION

A virtual reality application for self-instructed practice of systematic clinical observation using the ABCDE approach can be developed with sufficient testing by inexperienced health students and professionals.

Interest in using patient portals among adolescents in mental health care - a cross-sectional study

INTRODUCTION

Adolescents in mental health care may benefit from using patient portals to access personalised information about their health and treatment. While no studies have considered the interest in using patient portals among adolescents in mental health care, factors such as patient activation, self-reported health, depressive symptoms, diagnosis, healthcare utilisation, and eHealth literacy have been found to be associated with interest in and use of patient portals in other patient groups. Therefore, the aim was to explore the associations between interest in using patient portals and patient activation, self-reported health, depressive symptoms, diagnosis, healthcare utilisation and eHealth literacy among adolescents in specialist mental health care.

METHODS

A cross-sectional study among adolescents between 12 and 18 years of age receiving or having received treatment at four different specialist child and adolescent mental healthcare services across Norway. The adolescents´ answers to the questionnaire were linked to data on their healthcare utilisation and ICD-10 diagnoses from the Norwegian Patient Registry. The data were analysed using descriptive statistics and bivariate tests.

RESULTS

The 53 adolescents who participated, had a mean age of 15 years and 68% of them identified as female. Two out of three (64%) were interested in using patient portals. Most of the factors were not associated with interest in using patient portals. However, adolescents with mental and behavioural disorders (F diagnoses, 75% interested) were more interested in using patient portals compared to those with symptoms and signs involving cognition, perception, emotional state, and behaviour (R diagnoses, 31% interested).

CONCLUSION

Except for mental health diagnosis, this study did not identify any specific factors likely to impact patient portal interest among adolescents in specialist mental health care.

Interest in and Experience with the Use of Patient Portals Among Adolescents in Mental Health Care

Patient portals hold the potential to support patients and enhance treatment, yet some concerns exist for adults in mental health care and adolescents in general. Due to limited studies on patient portal use in adolescent mental health care, the aim was to examine the interest in and experiences with the use of patient portals among adolescents in mental health care. In a cross-sectional survey, adolescent patients in specialist mental health care across Norway were invited between April and September 2022. The questionnaire included questions on their interests in and experiences with using patient portals. Fifty-three (8,5%), adolescents between 12-18 (mean: 15) responded, of which 64 % were interested in using patient portals. Almost half of the respondents would share access to their patient portal with healthcare providers (48 %) and designated family members (43 %). One-third had used a patient portal, where 28 % had used it to change an appointment, 24 % to see their medications and 22 % to communicate with healthcare providers. The knowledge from this study can be used to inform the set-up of patient portal services for adolescents in mental health care.

How to Represent the Patient Voice in the Electronic Health Record?

There is an agreement among patients, professionals, as well as leaders, and governance that person-centered care (PCC) is central to care quality. PCC care is a sharing of power to ensure that the answer to: "What matters to you?" drives care decisions. Thus, the patient voice needs to be represented in the EHR to support both patients and professionals in the shared decision-making process and enable PCC. The aim of this paper is therefore to investigate how to represent the patient voice in an EHR. This was a qualitative study of a co-design process with six patient-partners and a team of healthcare personnel. The result of the process was a template for the information needed to represent the patients' voice in the EHR based on three questions: "What is important for you right now?". "What matters to you in your life?". "What do you want your care team to know about your history?".

Identifying individuals with complex and long-term health-care needs using the Johns Hopkins Adjusted Clinical Groups System: A comparison of data from primary and specialist health care

AIMS

This study aimed to present the Johns Hopkins Adjusted Clinical Groups (ACG) System risk stratification profile of a total adult population of somatic health-care users when using data from either general practitioners (GPs) or hospital services and to compare the number and characteristics of individuals identified as having complex and long-term health-care needs in each data source.

METHODS

This was a registry-based study that included all adult residents (N=168,285) in four municipalities in Central Norway who received somatic health care during 2013. Risk profiles were generated using the ACG System based on age, sex and diagnoses registered by GPs or the local hospital. ACG output variables on number of chronic conditions, frailty and concurrent resource utilisation were chosen as indicators of complexity.

RESULTS

Nearly nine out of 10 (83.9%) of the population had been in contact with a GP, and 35.4% with the hospital. The mean number of diagnoses (3.0) was equal in both sources. A larger proportion of the population had higher risk scores in all variables except frailty when comparing hospital data to GP data. This was also found when comparing individuals identified as having complex and long-term health-care needs. A similar proportion of the population was found to have complex and long-term health-care needs (hospital 6.7%, GP 6.3%), but only one in five (21.5%) were identified in both data sets.

CONCLUSIONS

As data from GPs and hospitals identified mostly different individuals with complex and long-term health-care needs, combining data sources is likely to be the best option for identifying those most in need of special attention.

How Did People with Prediabetes Who Attended the Diabetes Prevention Education Program (DiPEP) Experience Making Lifestyle Changes? A Qualitative Study in Nepal

Diabetes can be prevented through lifestyle modification in the prediabetic phase. A group-based lifestyle intervention called 'Diabetes Prevention Education Program' (DiPEP) was tested recently in Nepal. The present study aimed to explore experiences of making lifestyle changes among people with prediabetes participating in the DiPEP. This qualitative study, with semi-structured interviews of 20 participants, was conducted 4-7 months following DiPEP intervention. Data analysis was performed by thematic analysis. The results included four themes, understanding that diabetes could be prevented, lifestyle changes made, hurdles to overcome, and experiencing benefits leading to sustained change. Some participants said they felt relieved to know that they had a chance to prevent diabetes. The participants talked mostly about making changes in diet (reducing carbohydrate intake) and physical activity (starting exercises). Obstacles mentioned included a lack of motivation and a lack of family support to implement changes. Experiencing benefits such as weight loss and reduced blood sugar levels were reported to lead them to maintain the changes they had made. Understanding that diabetes could be prevented was a key motivator for implementing changes. The benefits and hurdles experienced by the participants of the present study can be taken into consideration while designing lifestyle intervention programs in similar settings.

Views on patient portal use for adolescents in mental health care - a qualitative study

BACKGROUND

Digitalization of health care has opened up for new ways to involve and engage patients. With this, increased attention has been put on digital patient portals. There exists some research on patient portals for adolescent patients in general and for adults in mental health care. However, no studies on patient portals for adolescents in mental health care have been identified in a recent review. The aim was therefore to explore the views on using patient portals for adolescents in mental health care among persons involved in and/or being affected by the introduction of a patient portal.

METHODS

A qualitative study was conducted using individual semi-structured interviews with 14 persons who were healthcare providers in child and adolescent mental health care, young representatives from the user panel, or persons affiliated with an EHR-project introducing a patient portal. The main questions addressed their views on introducing patient portals for adolescents in mental health care and how patient portals and access to clinical notes can affect them and their treatment.

RESULTS

The findings were categorised into four main themes; "Does access to a patient portal help or harm adolescents?", "Who decides access?", "Mostly a political goal" and "Need for support and competency". Informants mentioned situations in which both adolescents' and parents' access to a patient portal could help adolescents in mental health care, but also where it could potentially harm their treatment and threaten confidentiality. Most informants thought that healthcare providers should have the autonomy to determine which information should be shared with whom, but also requested guidelines to ensure equal practice and support in difficult situations. Some perceived patient portals as the result of a political decision, rather than healthcare providers´ wishes, while others described it as a necessary development towards democratization.

CONCLUSION

The informants' views varied from thinking that a patient portal could support adolescents in mental health care, to worrying that it could be detrimental to the treatment. Informants emphasized that the management should facilitate training and support for healthcare providers in using patient portals and telehealth.

Psychological safety in European medical students' last supervised patient encounter: A cross-sectional survey

OBJECTIVE

To investigate the association between European medical students' psychological safety in and experiences from their last supervised patient encounter.

MATERIALS AND METHODS

A cross-sectional online survey among European medical students. Bivariable and multivariable linear regression was used to explore the associations between the dependent variable psychological safety and independent variables concerning students' experiences from their last supervised patient encounter.

RESULTS

A total of 886 students from more than 25 countries participated. The variables most strongly associated with psychological safety were supervisor coaching and modelling behaviour, adjusted beta 0.4 (95%CI 0.3 to 0.5) and 0.1 (95%CI 0.1 to 0.2) per unit respectively on a one-to-five-point scale, and studying in Northern Europe, adjusted beta 0.4-0.5 compared to other regions. There was a weak negative association (reduced score on psychological safety) for being supervised by a medical doctor with <5 years' experience and a positive association for student confidence. Student gender, student seniority, speciality, whether peers were present, number of previous encounters with the supervisor and supervisor articulation and exploration behaviour were not associated in multivariable analysis.

CONCLUSION

Coaching might be a good primary focus to improve supervision practices, as participation with feedback is known to be beneficial for learning and coaching was strongly associated with psychological safety. Supervisors in western, eastern, and southern Europe might have to work harder to create psychological safety than their northern colleagues.

What Aspects of Supervised Patient Encounters Affect Students' Perception of Having an Excellent Learning Outcome? A Survey Among European Medical Students

Background

To investigate whether supervisor behavior, students' participation and approach, and psychological safety were associated with self-reported excellent learning outcome from supervised encounters with patients among European medical students.

Methods

A cross-sectional, online survey among European medical students asking about their latest clinical supervision experience. Associations were examined with logistic regression.

Results

Students (N=908) from >25 countries reported on experiences from supervised patient encounters in most types of hospital departments and general practice. One out of six (17%) students perceived the learning outcome as excellent. In the multivariable logistic regression, this was independently associated with supervisor role modelling (odds ratio (OR) 2.1, 95% confidence interval (CI) 1.5-3.0) and addressing learning goals (OR 1.4, 95% CI 1.1-1.7), students' approach to learning (OR 1.7, 95% CI 1.0-3.0) and psychological safety (OR 1.5, 95% CI 1.1-2.0). Supervisors being present during the patient encounter, coaching students or asking questions to have students express their thinking, and student participation in examination and/or history taking was not associated with perceived excellent learning outcome.

Conclusion

We encourage supervisors to recognize that students are beginners in most supervised clinical settings and often appreciate having learning goals addressed, behavior and thinking role modelled, and psychological safety established before they participate more fully.

Usability Evaluation of the Preoperative ISBAR (Identification, Situation, Background, Assessment, and Recommendation) Desktop Virtual Reality Application: Qualitative Observational Study

BACKGROUND

Systematic communication, such as the ISBAR (identification, situation, background, assessment, recommendation) approach, comprises a generic, transferable nontechnical skill. It can be used during the handover of patients set to undergo surgery and can be practiced in various ways, including virtual reality (VR). VR increasingly has been implemented and valued in nursing education as a positive contribution to teach students about pre- and postoperative nursing. A new nonimmersive 3D learning activity called the Preoperative ISBAR Desktop VR Application has been developed for undergraduate nursing students to learn preoperative handover using the ISBAR approach. However, the usability of this learning activity has not been studied.

OBJECTIVE

This study aimed to investigate how second-year undergraduate nursing students evaluated the usability of the Preoperative ISBAR Desktop VR Application.

METHODS

This was a qualitative study with observation and interviews. The inclusion criteria were undergraduate second-year nursing students of varying ages, gender, and anticipated technological competence. The System Usability Scale (SUS) questionnaire was used to get a score on overall usability.

RESULTS

A total of 9 second-year nursing students aged 22-29 years participated in the study. The average score on the SUS was 83 (range 0-100), which equals a "B" on the graded scale and is excellent for an adjective-grade rating. The students expressed increased motivation to learn while working in self-instructed desktop VR. Still, a few technical difficulties occurred, and some students reported that they experienced some problems comprehending the instructions provided in the application. Long written instructions and a lack of self-pacing built into the application were considered limitations.

CONCLUSIONS

The nursing students found the application to be usable overall, giving it an excellent usability score and noting that the application provided opportunities for active participation, which was motivational and facilitated their perceived learning outcomes. The next version of the application, to be used in a randomized controlled trial, will be upgraded to address technological and comprehension issues.

Learning from clinical supervision - a qualitative study of undergraduate medical students' experiences

INTRODUCTION

Clinical supervision is necessary to ensure students' learning and patient safety. There is limited research on how medical students' actions play into the dynamic of learning from clinical supervision. We aimed to explore undergraduate medical students' experiences with learning from clinical supervision, focusing on students' actions and interactions.

MATERIALS AND METHODS

A qualitative study using semi-structured interviews with medical students at two English and four Norwegian universities. The main topics were students' experiences with clinical supervision, what students' felt helped them learn, and how they acted. Transcribed interviews were analysed thematically.

RESULTS

22 students participated. The actions participants described performing during supervision ranged from staying quiet to initiating active participation. They described that learning was more likely to take place when they took initiative, acted on opportunities to participate, and focused their attention on learning. When they did not feel safe, they were more likely to stay quietly in the background. When participants felt concerned for patients' welfare their attention shifted away from learning. While if they were appropriately confident, they engaged in learning.

CONCLUSION

Feelings of safety, patients' being cared for, and confidence impacted on students' actions and thus learning. Our findings suggest that when students feel psychologically safe, they are more likely to act and interact during clinical supervision. One way to improve psychological safety is to foster relationships between students and supervisors.

General practitioners' experiences of being involved in local public health work in Norway. A qualitative study

AIM

The aim was to explore how general practitioners experienced being involved in local public health work and how they worked with prevention and health promotion clinically after the introduction of the Public Health Act in 2012.

DESIGN, SETTING AND SUBJECTS

Qualitative study with focus groups interviews with 18 GPs from different municipalities in Norway.

RESULTS

The GPs said that they either had not at all or only to a limited extent been involved in local public health work in their municipalities. They reported finding it hard to prioritize individual disease prevention and health promotion in their clinical work. GPs thought of health promotion as something that mainly concerned healthy people at a group level.

CONCLUSIONS

Based on the experiences of the GPs in this study, there is a gap between governmental expectations to the role of GPs in public health, and how it works in practice.KEY POINTSWith the Norwegian Public Health Act launched in 2012, GPs were expected to contribute to better population health in their clinical work and as data providers to local public health surveillance.The GPs interviewed in this study said they had not been involved in local public health work, and they found it hard to give disease prevention and health promotion priority in their clinical work.GPs expressed various perceptions of what prevention and health promotion entails.

Relevant vs non-relevant subspecialist for patients hospitalised in internal medicine at a local hospital: which is better? A retrospective cohort study

Background

Studies of the treatment of patients in-hospital with a specific diagnosis show that physicians with a subspecialisation relevant to this diagnosis can provide a better quality of care. However, studies including patients with a range of diagnoses show a more negligible effect of being attended by a relevant subspecialist. This project aimed to study a more extensive set of patients and diagnoses in an environment where the subspecialist present could be controlled. Thus, this study investigated whether being attended by a physician with a subspeciality relevant to the patient’s primary diagnosis was prospectively associated with readmission, in-hospital mortality, or length of stay compared to a physician with a subspeciality not relevant to the patient’s primary diagnosis.

Methods

We have conducted a retrospective register-based study of 11,059 hospital admissions across 9 years at a local hospital in south-eastern Norway, where it was possible to identify the physician attending the patients at the beginning of the stay. The outcomes studied were emergency readmissions to the same ward within 30 days, any in-hospital mortality and the total length of stay. The patients admitted were matched with the consultant(s) responsible for their treatment. Then, the admissions were divided into two groups according to their primary diagnosis. Was their diagnosis within the subspeciality of the attending consultant (relevant subspecialist) or not (non-relevant subspecialist). The two groups were then compared using bivariable and multivariable models adjusted for patient characteristics, comorbidities, diagnostic group and physician sex.

Results

A relevant subspecialist was present during the first 3 days in 8058 (73%) of the 11,059 patient cases. Patients attended to by a relevant subspecialist had an odds ratio (OR) of 0.91 (95% confidence interval 0.76 to 1.09) for being readmitted and 0.71 (0.48 to 1.04) for dying in the hospital and had a length of stay that was 0.18 (− 0.07 to 0.42) days longer than for those attended to by a non-relevant subspecialist.

Conclusions

This study found that patients attended by a relevant subspecialist did not have a significantly different outcome to those attended by a non-relevant subspecialist.

Participants' experiences from group-based treatment at multidisciplinary pain centres - a qualitative study

OBJECTIVES

The aim of the study was to explore the experiences of participants in non-pharmacological group-based treatments delivered as part of a randomised controlled trial at Norwegian tertiary care pain centres.

METHODS

Individual semi-structured interviews with 15 persons were conducted. The data were analysed with a descriptive thematic cross-case analysis based on the method of systematic text condensation.

RESULTS

All participants talked about some aspects of the group-based treatments as a positive experience, but mainly the outcome was in line with their expectations; they hoped it would reduce their pain but did not expect it. There were no clear-cut differences in the experiences between the participants from the two different intervention groups. The content was experienced as both relevant and interesting but also to introduce concepts that were difficult to grasp and understand. Similarly, the experiences of participating in a group-based treatment were mostly stimulating but could also be challenging because of an expectancy of sharing personal stories. Although experiencing few changes to their pain they came away with techniques and lessons that were valuable to them.

CONCLUSIONS

In this study, taking part in group-based treatment was perceived as giving positive and valuable lessons, due to relevant content and learning from the professionals and fellow participants, but without any clear indication of reduced pain. Approval from ethical committee number 10260 REK Midt.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT04057144.

The short-term effect of a modified comprehensive geriatric assessment and regularly case conferencing on neuropsychiatric symptoms in nursing homes: a cluster randomized trial

Aims

To investigate the short-term effect of implementing a modified comprehensive geriatric assessment and regularly case conferencing in nursing homes on neuropsychiatric symptoms.

Background

Neuropsychiatric symptoms are common and may persist over time in nursing home residents. Evidence of effective interventions is scarce.

Design

A parallel cluster-randomised controlled trial.

Methods

The intervention was monthly standardised case conferencing in combination with a modified comprehensive geriatric assessment. The control group received care as usual.

Main outcome measure.

The total score on the short version of the Neuropsychiatric Inventory (NPI-Q, 12-items).

Results

A total of 309 residents at 34 long-term care wards in 17 nursing homes (unit of randomisation) were included. The intervention care units conducted on average two case conference-meetings (range 1–3), discussing a mean of 4.8 (range 1–8) residents. After 3 months, there were no difference of NPI-Q total score between the intervention (-0.4) and the control group (0.5) (estimated mean difference = -1.0, 95% CI -2.4 to 0.5, p = 0.19). There was a difference in favour of the intervention group on one of the secondary outcome measures, the apathy symptoms (-0.5 95% CI: -0.9 to -0.1, p = 0.03).

Conclusion

In this study there were no short-term effect of case conferencing and modified comprehensive geriatric assessments after three months on the total score on neuropsychiatric symptoms. The intervention group had less apathy at 3 months follow-up compared to those receiving care as usual. The findings suggest that a more comprehensive intervention is needed to improve the total Neuropsychiatric symptoms burden and complex symptoms.

Trial registration

Due to delays in the organisation, the study was registered after study start, i.e. retrospectively in Clinicaltrials.gov # NCT02790372 at https://clinicaltrials.gov/; Date of clinical trial registration: 03/06/2016.

Caregiving, participation, and quality of life of closest next of kin of persons living with Spinal Cord Injury in Norway

OBJECTIVES

To investigate how next of kin of persons with spinal cord injury (SCI) experience various life areas in terms of caregiving, participation, and quality of life (QoL), and the impact of personal characteristics of next of kin and SCI characteristics.

DESIGN

Survey among next of kin linked to data on persons with SCI in the Norwegian SCI Registry.

PARTICIPANTS

Seventy-three next of kin identified by a person with SCI.

METHODS

The outcome measures were caregiving (4 measures), participation (1 measure), and QoL (2 measures).

RESULTS

The participants (73% partners, 73% female, mean age 56.4 years) gave various support to the person with SCI and found it important to care and were happy to do so. Three out of four reported good mental health and life satisfaction, while one-fourth reported high levels of caregiver strain, especially related to emotional adjustments. Higher levels of caregiver strain were reported by participants of working age (<67 years), and by those with middle level education.

CONCLUSION

The majority of next of kin of persons living with SCI in Norway are doing well in most life areas. Caregiver strain may be reduced by strengthening the ability of next of kin to cope with emotional challenges.

Fitness center use and subsequent achievement of exercise goals. A prospective study on long-term fitness center members

Background

Knowledge on the relationship between fitness center use and long-term members’ subsequent goal achievement is limited. Therefore, the aim was to investigate the prospective association between the use of fitness centers during 18 months and subsequent self-reported goal achievement among long-term members.

Methods

This was a registry- and survey-based longitudinal study of 2851 people who had been members at a Norwegian fitness center chain for more than two years. Fitness center use from December 2016 to June 2018 was obtained from registry data. Subsequent goal achievement was measured in a survey in June 2018, assessed by a 1–100 visual analogue scale, and a score between 0 and 50 was defined as low goal achievement.

Results

Visiting the fitness center frequently and regularly, and having frequent group activity bookings were associated with higher subsequent self-reported goal achievement. Participants with fewest visits (1–57 days) during 18 months were more likely to report low goal achievement than participants with most visits (118–543 days) (OR = 8.5; 95% CI 6.3–11.4). Fitness trainer bookings was not clearly associated with subsequent goal achievement.

Conclusions

Frequent and regular long-term fitness center use were associated with higher subsequent self-reported goal achievement.

The effect of initial support on fitness center use in new fitness center members. A randomized controlled trial

•

There is a lack of research on what fitness centers do to support new members.

•

The effect of initial support delivered via telephone and e-mail was investigated.

•

There was an effect on bookings with a fitness trainer first six months.

•

There was no effect on days with visits or membership duration during four years.

•

More visits the first six months were associated with longer membership duration.

This provider and participant blinded parallel-group randomized controlled trial aimed to investigate if initial support given to new members via telephone and e-mail, compared to self-directed use, had an effect on booking with a fitness trainer, number of visits to the center, and membership duration. Participants included 356 new members, 174 randomized to the intervention group, and 182 to the control group. The intervention group received support to use the fitness center facilities through two phone calls and one e-mail over the first eight weeks of their membership. The control group got usual practice, which is self-directed use.

Participants in the intervention group were more likely to book at least one session with a fitness trainer during the first six months (odds ratio 1.6, 95% confidence interval (CI) 1.0–2.5). However, the intervention did not influence the number of visits (mean difference after four years −11.7 days, 95% CI −34.8 to 11.3) or time to membership termination during the follow-up period (hazard ratio 1.1, 95% CI 0.8–1.3).

In conclusion, initial support to use the fitness center facilities given to new fitness center members via telephone and e-mail increased the proportion of bookings with a fitness trainer during the first months of the membership, but it did not have an effect on the number of visits or membership termination during four years.

Participation and quality of life in persons living with spinal cord injury in Norway

Objectives

To describe the association between sociodemographic and spinal cord injury characteristics, of people living with spinal cord injury, and participation and quality of life, and to study the association between participation and quality of life in this group of people.

Design

Persons registered in the Norwegian Spinal Cord Injury Registry after post-acute rehabilitation between 2011 and 2017 were invited to participate in a survey in 2019 when they were in a community setting.

Subjects

A total of 339 people living with spinal cord injury.

Methods

The Frequency scale and Restrictions scale of the Utrecht Scale for Evaluation of Rehabilitation-Participation were used to measure participation. Quality of life was measured as life satisfaction with the World Health Organization Quality of life assessment (WHOQoL-5) and mental health was measured using the Mental Health subscale (MHI-5).

Results

Overall, sociodemographic characteristics were more prominently associated with quality of life and participation than were spinal cord injury characteristics. Currently working as main activity and having a family income in the highest quartile were associated with higher scores on all 4 measures of participation and quality of life. There was a strong gradient between higher level of participation (frequency and restrictions) and better quality of life.

Conclusion

Participation was strongly associated with life satisfaction and mental health in people living with spinal cord injury. This indicates that participation issues should be given greater priority during post-acute rehabilitation, follow-up and subsequent care efforts provided in the community.

Digital secondary prevention follow-up after percutaneous coronary intervention (PCI) at home: what are the users perspectives?

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): LHL Hospital Gardermoen Bergesen Foundation

Digital Secondary Prevention Follow-up After Percutaneous Coronary Intervention (PCI) at Home:

What are the Users Perspectives?

Background

Secondary prevention for patients with established CHD is the mainstay of cardiovascular rehabilitation, but is not accessible to all eligible patients. Digital delivery offers a way to widen participation in secondary prevention to PCI patients, but little is known about users’ preferences.

Purpose

The purpose of this qualitative study was to explore service users, carers and health professionals views about potential challenges experienced in secondary prevention after PCI and preferences for support to inform the development of a digital home program.

Methods

A series of three focus group interviews were conducted in a broad user panel with former PCI patients (4), next-of-kin (1) and interdisciplinary health care professionals (4) between March 2017 and September 2019. Data was audiotaped, transcribed verbatim and analysed using content analysis.

Results

Three main themes and sub-themes on challenges and preferences for digital follow-up were identified: (1) Technology: feasibility including  safety, integration with known platforms, functionality, and user-friendly navigation were major assets, as well as the capability of monitoring medication adherence, smoking cessation and physical activity. (2) Communication: interactive, direct, clear, supportive, encouraging, visualizing, humorous, using virtual meeting rooms, as well as including direct responses on patients’ self-motivation and achieved goals and (3) Health information: basic step-by-step facts and questions-and-answers (FAQ), being practical, visual, and including side effects of medications and health services navigation.

Conclusion

User perspectives from former patients, next-of-kin and health care professionals reveal a preference for digital secondary prevention which offers functionality, communication, and health information during follow-up at home after a PCI.

The effect of self-practicing systematic clinical observations in a multiplayer, immersive, interactive virtual reality application versus physical equipment: a randomized controlled trial

This study aimed to investigate whether group self-practice of systematic clinical observation using the airway, breathing, circulation, disability and exposure (ABCDE) approach in a multiplayer, immersive, interactive virtual reality (VR) application provided a non-inferior learning outcome compared to practicing with physical equipment in first-year medical and nursing students. The study was a non-inferior, parallel-group randomized controlled trial. After a 15-min introduction session on the ABCDE approach, all students were randomly allocated to practice ABCDE in groups of three for 20 min either in a fully immersive, interactive, multiplayer virtual reality application (the VR group) or with physical equipment (the TP group). The primary outcome was the number of students who documented all predefined observations in the correct order of the ABCDE approach on a practical test performed immediately after group practice. A total of 84% of all eligible students participated, with 146 students in the VR group and 143 in the TP group. On the primary outcome, 20% in the VR group and 21% in the TP group got everything correct (absolute difference 1% point, one-sided 95% confidence interval 1.0-8.8% points), showing non-inferiority of the virtual reality application. For other outcomes, the results were mostly similar between the groups. Group self-practice of the ABCDE approach in multiplayer, immersive, interactive virtual reality application was non-inferior to practice with physical equipment.

Participants' views and experiences from setting up a shared patient portal for primary and specialist health services- a qualitative study

Background

Recently, there has been an increasing focus among healthcare organisations on implementing patient portals. Previous studies have mainly focussed on the experiences of patient portal use. Few have investigated the processes of deciding what content and features to make available, in particular for shared portals across healthcare domains. The aim of the study was to investigate views on content and experiences from the configuration process among participants involved in setting up a shared patient portal for primary and specialist health services.

Methods

A qualitative study including 15 semi-structured interviews with persons participating in patient portal configuration was conducted from October 2019 to June 2020.

Results

Whether a shared patient portal for all the health services in the region should be established was not questioned by any of the informants. It was experienced as a good thing to have numerous participants present in the discussions on configuration, but it also was said to increase the complexity of the work. The informants considered a patient portal to be of great value for patient care, among other things because it would lead to improvements in patient follow-up and increased patient empowerment. Nevertheless, some informants advocated caution as they thought the patient portal possibly could lead to an increase in healthcare providers’ workloads and to anxiety and worries, as well as to inequality in access to health care among patients. The findings were categorized into the themes ‘A tool for increased patient involvement’, ‘Which information should be available for the patient’, ‘Concerns about increased workload’, ‘Too complex to use versus not interesting enough’, ‘Involving all services’ and ‘Patient involvement’.

Conclusions

Establishing a shared patient portal for primary and specialist health services was considered unproblematic. There was, however, variation in opinions on which content and features to include. This variation was related to concerns about increasing the workload for health care providers, causing anxiety and inequality among patients, and ensuring that the solution would be interesting enough to adopt.

Evidence of validity for the Norwegian version of the interprofessional collaborative competency attainment survey (ICCAS)

This was a validation study of the Norwegian version of The Interprofessional Collaborative Competency Attainment Survey (ICCAS). ICCAS consists of 20 retrospective pre- and post-questions, where respondents rate their agreement with regard to self-assessed competencies after participating in interprofessional education courses. It has been validated across various settings. The questionnaire was translated using the back-translation technique. We investigated evidence of validity regarding content, response process, and internal structure. Data were obtained from health and social care students (n = 1440, response rate 42.8%) participating in 12 different interprofessional courses in seven education institutions in Norway using a cross-sectional design. Exploratory factor analysis indicated one retracted factor for pre-scores and one retracted factor for post-scores. High McDonald's omega values indicated good internal consistency. Item deletion did not improve the scale's overall consistency on pre- or post-scores. We observed higher mean post-scores than pre-scores with moderate-to-large effect sizes, indicating a positive change in self-assessed interprofessional capabilities after training. Our findings indicate that the Norwegian version of ICCAS is a valid tool that may be implemented across a wide range of interprofessional education courses. Finally, our findings support earlier recommendations that ICCAS should be analyzed at an overall level to address change in interprofessional capabilities.

"No one wants you" - a qualitative study on the experiences of receiving rejection from tertiary care pain centres

Background and aims Four out of 10 referrals to tertiary care pain centres in Norway are not granted pain centre treatment, confirming earlier research on that this group of patients struggle to access the highest standard of care. Still, no study investigating how people with chronic pain experience rejections from pain centres was found. The aim of the study was therefore to investigate how people with chronic pain experience receiving a rejection from tertiary care pain centres after being referred by their general practitioners (GPs). Methods This was a qualitative study with semi-structured individual interviews with 12 persons, seven men and five women, rejected from the four different pain centres in Norway. The data were analysed thematically using systematic text condensation. Results The pain centre rejection created strong reactions, partly because the rejection was perceived as a refusal from the health care system as a whole. This was especially so because the pain centre was regarded as the last remaining treatment option, and given the rejection, they were now declined help by the experts in the field. Even though some informants had received an explanation for why they had not been granted pain centre treatment, a prominent experience was that the informants found it difficult to understand why their referral had been rejected given the severity of their pain. The incomprehensibility of the rejection together with a feeling of lack of future treatment options, increased the hopelessness and frustration of their situation and made it challenging to move on and search for help elsewhere. Conclusions The experiences with the pain centre rejections indicate that the rejection can have grave consequences for each individual in the following months. An improved system for how to handle expectations towards referrals, including prepare for the possibility of rejection and how to follow up a rejection, seems warranted. Implications Because a pain centre rejection most likely is received by persons in a vulnerable position, there should be available health care services to help them understand the rejections. And furthermore, help them to move from disappointment and hopelessness, towards an experience of empowerment and reorientation, by for instance planning further actions and interventions, and thereby, acknowledge their need for help.

Translation and cultural adaptation of the Communication Assessment Tool (CAT), developing a Danish and Norwegian version

OBJECTIVE

To translate and cultural adapt the 14-item Communication Assessment Tool (CAT) into Norwegian and Danish, making them as similar as possible.

DESIGN

This was a translation and validation study including individual interviews for content and face validity and a patient survey for internal consistency and floor-ceiling effect.

SETTING

Outpatient clinic at the Department of Internal Medicine, Lillebaelt Hospital, Denmark and a Norwegian general practice.

PARTICIPANTS

Ten patients were included for individual interviews and 440 participants completed the survey.

MAIN OUTCOME MEASURE

Translation and validation of the CAT.

RESULTS

Despite minor differences in the use of words in the translated versions of CAT, the final versions were very similar. Based on the content and face validation and after agreement with the developers, it was decided to include a 'non-applicable' answering option, not a part of the original version. The use of 'non-applicable' for each item ranged from 0% to 30% in Norway and from 0% to 6.1% in Denmark. The overall CAT score, i.e. items rated excellent, were 55.5% in Norway and 50.3% in Denmark. For each item, the CAT score ranged between 31.3% and 69.8% in Norway and 33.7% and 57.4% in Denmark.

CONCLUSION

The translated and validated CAT can be used to measure patients' perspectives on clinicians' communication skills in Denmark and Norway.

Changes in performance during repeated in-situ simulations with different cases

Introduction

The aim was to describe changes in the performance of clinical actions, during repeated in-situ simulations with different cases, by teams of healthcare professionals with different experiences of the systematic clinical observation of deteriorating patients, after an introduction to the Airways, Breathing, Circulation, Disability, Environment/Exposure (ABCDE) approach.

Methods

A descriptive observational study was conducted of repeated in-situ simulations using a patient simulator (SimMan 3G), carried out by teams in a public nursing home (NH, least experienced), an out-of-hours general practice (OOH-GP) service and a hospital emergency department (ED, most experienced). The cases had similar clinical presentations but different underlying diagnoses unknown to the teams. Four blinded clinical experts independently assessed the simulations on the basis of transcripts, providing comments, an overall score and scores for the clinical actions.

Results

The assessors commented on the overall lack of a systematic ABCDE approach in the NH and OOH-GP in all simulations, while the comments for the ED concerned the choice of treatment. Across the teams, the overall score was highest in the first simulation and second highest in the third simulation. The team in the NH received low overall scores for all simulations, but the last simulation received markedly better scores on the clinical actions. The teams in the OOH-GP and ED had no such clear pattern in the scores for clinical actions and thus no indications of improvement with repeated simulations.

Conclusion

The observation in this study was that the overall assessment by the blinded assessors showed no consistent improvement in clinical actions from repeated in-situ simulations, and the teams did not seem to adhere to the ABCDE approach throughout the simulations. This indicates that the teams were not able to apply their newly acquired experiences of using the ABCDE approach from one case to another, different case.

Is individual practice in an immersive and interactive virtual reality application non-inferior to practicing with traditional equipment in learning systematic clinical observation? A randomized controlled trial

BACKGROUND

The aim was to investigate if individual self-practice of the ABCDE approach (Airways, Breathing, Circulation, Disability, Exposure) in an immersive and interactive virtual reality (VR) application gave non-inferior learning outcome compared to using traditional equipment (TP) in first year medical and nursing students.

METHODS

A non-inferior parallel group randomized controlled trial. The study was linked to a regular teaching program conducted in August and September 2019. All students participated in a 15-min ABCDE introduction session, before they self-practiced the ABCDE approach for 20 min in either a fully immersive and interactive VR application using hand controllers with some haptic feedback (Individual VR) or with blood pressure gauge, ear-thermometer and oximeter (Individual TP). The primary outcome was the number of students who documented all the eight predefined observations in the ABCDE approach in the correct order in a practical test on an advanced simulator manikin with a time limit of 5 min, done immediately after the self-practice. The predefined one-sided non-inferiority limit was 13% points.

RESULTS

Of all eligible students, 84% participated in the study and randomly allocated to VR (n = 149) or TP (n = 140). The primary outcome showed non-inferiority of the VR application with 24.8% in individual VR doing all observations in correct order compared to 27.1% TP (absolute difference 2.3% points, one sided 95% CI 2.3 to 10.8). The secondary outcomes were similar between the groups, but more students in VR reported liking the way they practiced (absolute difference 46% points, 95% CI 36.5 to 56.6) and that it was a good way to learn (36.9% points, 95% CI 26.8 to 47). VR also scored high on the System Usability Scale (mean difference 6.4% points, 95% CI 2.8-10.1).

CONCLUSIONS

Individual self-practicing the ABCDE approach in VR was non-inferior to individual self-practicing with traditional equipment.

Rehabilitation in warm climate for young adults with inflammatory arthritis: A 12-month randomized controlled trial

OBJECTIVES

To investigate if an intensive rehabilitation programme, including intensive exercise and patient education, for young adults with inflammatory arthritis, conducted in a warm climate, has long-term effects on general health status compared with usual care.

DESIGN

Open randomized controlled trial.

PATIENTS

A total of 64 patients with inflammatory arthritis, aged 20-35 years.

METHODS

Patients underwent randomized allocation to an intensive 17-day rehabilitation programme in a warm climate (intervention group) or to usual care with no structured rehabilitation (control group). The primary outcomes were physical function, assessed by the "30-second Sit to Stand test"(30sSTS), and coping, measured by the "Effective Musculoskeletal Consumer Scale" (EC17).

RESULTS

A total of 64 patients (mean age 27.5 years, 62.5% female) were randomized. Thirty out of 32 patients completed the intervention. At 12-month follow-up, 7 patients were lost to follow-up; 4 from the intervention group and 3 from the control group. The intervention group showed significant improvement in the physical function test at 3 months; estimated mean difference (95% confidence interval): 5.5 (2.8-8.1), 6 months 3.6 (0.4-6.8) and 12 months 4.0 (0.0-7.9), compared with the control group. There were no differences in coping between the 2 groups at 3, 6 or 12 months.

CONCLUSION

Rehabilitation in a warm climate improves physical functioning, but not coping, in young adults with inflammatory arthritis.

'A lifebuoy' and 'a waste of time': patients' varying experiences of multidisciplinary pain centre treatment- a qualitative study

Background

The recognition of chronic pain as a biopsychosocial phenomenon has led to the establishment of multidisciplinary pain treatment facilities, such as pain centres. Previous studies have focussed on inpatient, group-based or time-limited multidisciplinary pain programmes. The aim was to investigate variation in patients’ experiences of attending individual outpatient multidisciplinary treatment at pain centres in Norway.

Methods

This was a qualitative study using semi-structured individual interviews with 19 informants. The informants were recruited among persons who after referral by their general practitioners 12 months prior had attended multidisciplinary pain treatment at a pain centre. The data were analysed thematically using systematic text condensation.

Results

The informants had received different treatments at the pain centres. Some had undergone only one multidisciplinary assessment in which a physician, a psychologist and a physiotherapist had been present, whereas others had initially been to a multidisciplinary assessment and then continued treatment by one or more of the professionals at the centre. Their experiences ranged from the pain centre as being described as a lifebuoy by some informants who had attended treatment over time, to being described as a waste of time by others who had only attended one or two multidisciplinary sessions. Prominent experiences included being met with understanding and a perception of receiving the best possible treatment, but also included disappointment over not being offered any treatment and perceiving the multidisciplinary approach as unnecessary.

Conclusions

There were large variations in the informants’ experiences in the pain centres. The findings indicate that the pain centres’ multidisciplinary approach can represent a new approach to living with chronic pain but may also not provide anything new. Efforts should be devoted to ensuring that the pain centres’ multidisciplinary treatment approach is aligned with their patients’ actual needs.

Contact with primary health care physicians before an acute hospitalisation

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission. Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services. Setting: Four municipalities in central Norway, 2012-2013. Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia. Main outcome measures: GP contact during the year and month before an emergency hospital admission. Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50-64 admitted with myocardial infarction or stroke. Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients' health care. KEY MESSAGES There is scarce knowledge about primary health care contact before an emergency hospital admission. The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure. More than 50% having monthly general practitioner contact before admission underscores the general practitioners' role in these patients' health care. Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

Considering formulation characteristics when prescribing and dispensing medicinal products for children: a qualitative study among GPs and pharmacists

BACKGROUND

Finding appropriate medicinal product formulations and dosage forms for children can be challenging. Knowledge about considerations behind which medicinal product to prescribe or dispense for children is lacking.

OBJECTIVE

To explore considerations of formulation characteristics of medicinal products made by GPs when prescribing and by pharmacists when dispensing medicines for children 0-6 years of age.

METHOD

A qualitative study was performed by conducting three semi-structured focus groups with GPs and three with pharmacists, using nearly identical thematic interview guides. Analysis was performed using systematic text condensation.

RESULTS

Both GPs and pharmacists considered whether children and parents were willing and able to use medicinal products such as tablets and poor-tasting liquids before prescribing and dispensing them. These considerations were commonly based on health care workers' prior experiences, although parents and sometimes children were asked about their experiences with solid formulations. For antibiotics, GPs primarily wanted to prescribe first-choice antibiotics according to guidelines. Parents' concerns about getting the child to take the medicinal product due to poor taste could lead to the prescription of second-choice antibiotics. The pharmacists sometimes changed the prescribed formulation at parents' request but never changed the type of antibiotic without contacting the prescriber.

CONCLUSION

Formulation characteristics strongly influenced which medicinal product children were prescribed and dispensed. Individualizing formulation choices for children through an increased collaboration between physicians, pharmacists and parents is suggested.

Register-based study showed that the age when children were prescribed antibiotic tablets and capsules instead of liquids increased from 2004 to 2016

AIM

We investigated the age when the prescriptions of oral antibiotic formulations for children from birth to 12 years of age changed from being mostly liquid to mostly solid and the associations between solid formulations and child, prescriber and medication characteristics.

METHODS

This register-based study comprised data from the Norwegian Prescription Database on oral antibiotics dispensed between 2004 and 2016 when both solid and liquid dosage forms were available in appropriate doses.

RESULTS

Just over 1.2 million prescriptions were studied, and the age when children were prescribed oral solid antibiotics gradually increased. The mean age of conversion from liquids to solid formulations was 6.9 years and ranged from 5.7 years in 2004/2005 to 7.9 years in 2015/2016. Patient factors associated with solid dosage forms were the children's increasing age and male gender. Practitioner factors were the prescribers' increasing age, male gender, being a general practitioner and issuing fewer than 23 paediatric antibiotic prescriptions per year. Medication factors were bad-tasting liquids and the size and shape of solid dosage forms.

CONCLUSION

The age when children were prescribed antibiotic tablets and capsules increased from 2004 to 2016. The medicine characteristics were quite consistent, so this was probably caused by a shift in formulation preferences.

Long-term members' use of fitness centers: a qualitative study

Background

Although the health benefits of physical activity are well documented, a large proportion of the population remains less active than recommended by current guidelines. Commercial fitness centers provide an opportunity to perform physical activity and exercise, but there has been little research focusing on ordinary members at commercial fitness centers. The aim of this study was therefore to explore what long-term members (> 2 years) wanted to achieve with their membership and to identify important factors that influenced them to use the fitness center as a means for physical activity.

Method

This was a qualitative study with 21 semi-structured individual interviews of adult long-term fitness center members in Trondheim, a city in Central Norway with approximately 190,000 inhabitants. The participants had been continuous fitness center members for more than two years and were asked about their experiences using a fitness center and what they wanted to achieve with the membership. The data was analyzed thematically with the method of systematic text condensation.

Results

The results were categorized into three main themes: “Health benefits and physical appearance”; “Accessible, safe, and comfortable to use”; and “Variety, flexibility, and support.” The participants stated that they wanted to achieve health benefits, but they also talked about physical appearance. The fitness center was mainly described as easily accessible and a comfortable place for physical activity. Some female participants emphasized the feeling of safety compared to outdoor activity. Variation in activities, making commitments, and getting support from staff and other members were factors contributing to use of the fitness center for physical activity.

Conclusion

Achieving desired health benefits and improving physical appearance were the main drivers for long-term members’ use of the fitness center. The fitness center was preferred due to the comfort of the facilities and the possibility to commit to specific exercise times and activities.

Twelve-month effect of chronic pain self-management intervention delivered in an easily accessible primary healthcare service - a randomised controlled trial

Background

To investigate the effects after twelve months related to patient activation and a range of secondary outcomes on persons with chronic pain of a chronic pain self-management course compared to a low-impact outdoor physical activity, delivered in an easily accessible healthcare service in public primary care.

Methods

An open, pragmatic, parallel group randomised controlled trial was conducted. The intervention group was offered a group-based chronic pain self-management course with 2.5-h weekly sessions for a period of six weeks comprising education that included cognitive and behavioural strategies for pain management, movement exercises, group discussions and sharing of experiences among participants. The control group was offered a drop-in, low-impact, outdoor physical activity in groups in one-hour weekly sessions that included walking and simple strength exercises for a period of six weeks. The primary outcome was patient activation assessed using the Patient Activation Measure (PAM-13). Secondary outcomes included assessments of pain, anxiety and depression, pain self-efficacy, sense of coherence, health-related quality of life, well-being and the 30-s Chair to Stand Test. Analyses were performed using a linear mixed model.

Results

After twelve months, there were no statistically significant differences between the intervention group (n = 60) and the control group (n = 61) for the primary or the secondary outcomes. The estimated mean difference between the groups for the primary outcome PAM was 4.0 (CI 95% -0.6 to 8.6, p = 0.085). Within both of the groups, there were statistically significant improvements in pain experienced during the previous week, the global self-rated health measure and the 30-s Chair to Stand Test.

Conclusions

No long-term effect of the chronic pain self-management course was found in comparison with a low-impact physical activity intervention for the primary outcome patient activation or for any secondary outcome.

Trial registration

ClinicalTrials.gov: NCT02531282. Registered on August 212,015

Requests for new oral antibiotic prescriptions in children within 2 days: a Norwegian population-based study

BACKGROUND

Children commonly refuse to take antibiotics, which may induce parents to request new antibiotic prescriptions with different pharmaceutical characteristics.

OBJECTIVES

To investigate prescription changes for children 0-12 years receiving oral liquid or solid antibiotic formulations and to explore the relationships between prescription changes and characteristics related to the child, prescriber and antibiotic.

METHODS

A population-based registry study based on data from the Norwegian Prescription Database (NorPD) from 2004 to 2016. Antibiotic prescription changes were defined as the dispensing of subsequent antibiotics with different pharmaceutical characteristics to the same child within 2 days after initial prescriptions. Data were analysed using multivariable logistic regression and generalized estimating equations.

RESULTS

Requests for new prescriptions followed 3.0% of 2 691 483 initial antibiotic prescriptions for children. Young children who received solid formulations (10.9%) and certain poor-tasting antibiotics (8.6%) had the highest proportions of new prescriptions. Penicillin V was most commonly changed, while macrolides/lincosamides dominated subsequent prescriptions. In order of magnitude, the characteristics associated with requests for new prescriptions were the children's ages, poor taste and concentration of liquids, size and shape of solids, prescribers born in recent decades, and girl patients. Reimbursed prescriptions and scored solids were associated with fewer requests.

CONCLUSIONS

While only 3% of the antibiotic prescriptions were changed, the preference of broad-spectrum over narrow-spectrum antibiotics for young children in this study mirrors international prescription patterns. Avoiding the costs of children's refusal and consequent changes may thus be a motivation for choosing more preferred antibiotics.

Short-term effect of a chronic pain self-management intervention delivered by an easily accessible primary healthcare service: a randomised controlled trial

OBJECTIVES

To investigate the effects on persons with chronic pain after 3 months of a group-based chronic pain self-management course compared with a drop-in, low-impact outdoor physical group activity on patient activation and a range of secondary outcomes.

DESIGN

An open, pragmatic, parallel group randomised controlled trial. Analyses were performed using a two-level linear mixed model.

SETTING

An easily accessible healthcare service provided by Norwegian public primary healthcare.

PARTICIPANTS

A total of 121 participants with self-reported chronic pain for 3 months or more were randomised with 60 participants placed in the intervention group and 61 placed in the control group (mean age 53 years, 88% women, 63% pain for 10 years or more).

INTERVENTIONS

The intervention group was offered a group-based chronic pain self-management course with 2.5-hour weekly sessions for a period of 6 weeks. The sessions consisted of education, movement exercises and emphasised group discussions. The control group was offered a low-impact outdoor group physical activity in 1-hour weekly sessions that consisted of walking and simple strength exercises for a period of 6 weeks.

MAIN OUTCOMES

The primary outcome was patient activation assessed using the Patient Activation Measure. Secondary outcomes measured included assessments of pain, anxiety and depression, pain self-efficacy, sense of coherence, health-related quality of life, well-being and the 30 s chair to stand test.

RESULTS

There was no effect after 3 months of the group-based chronic pain self-management course compared with the control group for the primary outcome, patient activation (estimated mean difference: -0.5, 95% CI -4.8 to 3.7, p=0.802).

CONCLUSIONS

There was no support for the self-management course having a better effect after 3 months than a low-impact outdoor physical activity offered the control group.

TRIAL REGISTRATION NUMBER

NCT02531282; Results.

Health care utilization and cost after discharge from a mental health hospital; an RCT comparing community residential aftercare and treatment as usual

BACKGROUND

Community residential aftercare (step-down) services can ease the transition after a mental health hospital stay for patients with severe mental illness (SMI).

AIMS

To investigate use of community and specialised mental health care services and costs in patients with SMI the first 12 months after discharge from a mental health hospital (MHH), comparing community residential aftercare (CRA) and treatment as usual.

METHODS

An open parallel group randomised controlled trial with 41 participants. Data on use of specialist services (hospital, ambulant treatment and outpatient treatment) and community services (residential stays, home help, home care nursing, mental health consultation) were collected from specialist and community registers and health records.

RESULTS

For the primary outcome, utilisation of community mental health services, the intervention group used, on average, 29% fewer hours (mean differences - 21.6 h, 95% CI -93.1 to 44.9, p = .096) with a cost saving of 29% (mean differences - 1845 EUR, 95% CI -8267 to 4171, p = .102), but the estimates were imprecise. For the secondary outcome, the study groups had the same total number of inpatient days (66 days), but the intervention group had on average of 13.4 fewer inpatient days in the mental health hospital (95% CI -29.9 to 0.9. p = .008). The number of inpatient admissions (mean difference - 0.9 admissions, 95% CI -3.5 to 1.5, p = .224) and readmissions (- 0.8, 95% CI -2.5 to 0.9. p = .440) was lower in the intervention group. The intervention group had on average a total cost saving of 38.5% (mean differences - 23,071 EUR, 95% CI -45,450 to 3027. p = .057). A post hoc multivariable regression analysis controlling for baseline characteristics gave a reduction in total cost in favour of the intervention group of - 19,781 EUR (95% CI -44,072 to 4509, p=,107).

CONCLUSION

In this study, it was not possible to draw a definite conclusion about the effect, due to the small sample and imprecision of the estimates. The direction of the results and size of the point estimate, in addition to findings in other studies, indicates that transferring patients ready for discharge from mental hospital to community residential aftercare can have the potential to reduce total consumption of health services and costs without increased hospital admissions.

TRIAL REGISTRATION

Registered in clinicaltrials.gov ( NCT01719354 ).

Usability testing of EirV3-a computer-based tool for patient-reported outcome measures in cancer

PURPOSE

Eir version 3 (V3) is an electronic tool for administration of patient-reported outcome measures (Eir-Patient) that immediately presents patient scores on the physician's computer (Eir-Doctor). Perceived usability is an important determinant for successful implementation. The aim of this study was to answer the following research question evaluated at the cancer outpatient clinics, in the patients' home, and at general practitioners' (GPs) offices: What are the number, type, and severity of usability issues evaluated by the patient (Eir-Patient module) and by the physician (Eir-Doctor module)?

METHODS

A usability evaluation using observations, think-aloud sessions, individual interviews and focus group interviews in cancer patients and their physicians was conducted. Identified usability issues were graded on a severity scale from 1 (irritant) to 4 (unusable).

RESULTS

Overall, 73 Eir registrations were performed by 37 patients, and used by 17 physicians in clinical consultations. All patients were able to complete the Eir-Patient symptom registration. Seventy-two usability issues were identified. None of them were graded as unusable. For the Eir-Patient module, 62% of the identified usability issues was graded as irritant (grade 1), 18% as moderate (grade 2), and 20% as severe (grade 3). For the Eir-Doctor module, 46% of the identified usability issues were graded as irritant, 36% as moderate and 18% as severe.

CONCLUSIONS

In the updated Eir version, issues in the severe and moderate categories have been changed, to optimize the usability of using real-time PROMs in clinical practice.

Policies Make Coherent Care Pathways a Personal Responsibility for Clinicians: A Discourse Analysis of Policy Documents about Coordinators in Hospitals

INTRODUCTION

In response to increase of patients with complex conditions, policies prescribe measures for improving continuity of care. This study investigates policies introducing coordinator roles in Norwegian hospitals that have proven challenging to implement.

METHODS

This qualitative study of policy documents employed a discourse analysis inspired by Carol Bacchi's 'What's the problem represented to be?'. We analysed six legal documents (2011-2016) and selected parts of four whitepapers presenting the statutory patient care coordinator and contact physician roles in hospitals.

RESULTS

The 'problem' represented in the policies is lack of coherent pathways and lack of stable responsible professionals. Extended personal responsibility for clinical personnel as coordinators is the prescribed solution. Their duties are described in terms of ideals for coherent pathways across conditions and contexts. System measures to support and orchestrate the individual patient's pathway (e.g. resources, infrastructure) are scarcely addressed.

CONCLUSIONS AND DISCUSSION

We suggest that the policies' construction of the 'problem' as a responsibility issue, result in that neither diversity of patients' coordination needs, nor heterogeneity of hospital contexts regarding necessary system support for coordinators, is set on the agenda. Adoption of rhetoric from diagnosis-specific standardized pathways obscures unique challenges in creating coherent pathways for patients with complex needs.

Disease-specific clinical pathways - are they feasible in primary care? A mixed-methods study

OBJECTIVE

To explore the feasibility of disease-specific clinical pathways when used in primary care.

DESIGN

A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings.

SETTING

Primary care and specialist care collaborating to manage care coordination.

RESULTS

Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year.

CONCLUSIONS

The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care. In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.

What are the contents of patient engagement interventions for older adults? A systematic review of randomized controlled trials

OBJECTIVE

To describe the contents of interventions reported in RCTs focusing on patient engagement of older adults.

METHODS

A systematic literature review based on a search for "patient engagement/activation/empowerment/involvement/participation". Interventions were classified according to: (i) specific components (micro level), (ii) single/multiple dimensions (educational, behavioral, affective) (meso level), and (iii) the studies' main educational, behavioral or affective dimension (macro level).

RESULTS

After screening 2749 articles, 35 were included. 20 unique components were identified, mostly behavioral or educational (45.5% each) (e.g., goal setting or written informational materials). Most interventions with a single-focus were classified as educational (31%), one was solely affective (3%). Half of the interventions covered more than one dimension, with four (11%) combining all three dimensions. Studies mainly focusing on the affective dimension included older participants (72 vs. 67 years), had a higher proportion of females (71% vs. 44%), and included other dimensions more frequently (67% vs. 31%) than did studies with a main focus on the educational dimension.

CONCLUSION

The contents of the interventions that focused on patient engagement of older adults tend to focus more on behavioral and educational dimensions than the affective dimension.

PRACTICE IMPLICATIONS

The possibility of adding the affective dimension into behavioral and/or educational interventions should be explored.

Keeping one step ahead: A qualitative study among Norwegian health-care providers in hospitals involved in care coordination for patients with complex needs

Introduction

Various efforts aim to enhance continuity of care for patients with long-term health-care needs. Since 2012, Norwegian hospitals are mandated to appoint individual care coordinators for patients with complex needs to ensure continuity in the care pathway. New roles must meld with current practice. Implementation has been slow. This study investigates current care coordination across hospital contexts, from the perspective of health-care providers, a scarcely researched area.

Methods

A qualitative study using semi-structured individual, duo, and group interviews with 16 purposefully selected Norwegian health-care providers from different hospitals, departments, professions and with various roles. A thematic cross-case analysis using systematic text condensation was performed.

Results

Common for the interviewees’ care coordination experiences was to “keep one step ahead.” The scope of their coordination activities varied from diagnostics and treatment to orchestrating long-term, cross-sectional multidisciplinary care. This work was often performed without designated resources. The interviewees applied experience, knowledge, and sensitivity when defining the patients’ needs and searching for resources to orchestrate coordination work. They strived to balance the needs of patients with the resources available and adjusted the continuity ambitions on behalf of their patients to what they considered doable in the relevant contexts. However, many told of negotiating special solutions for selected patients with particularly complex needs.

Discussion

Care coordination for patients with complex needs emerged as diverse and context-sensitive. Acknowledgement of coordination activities that go beyond established workflow routines and clinical pathways, together with flexible leadership support and accessible infrastructural resources are needed.

Predictors of Dropout From Inpatient Substance Use Treatment: A Prospective Cohort Study

Introduction:

Dropout from inpatient treatment for substance use disorder (SUD) is an ongoing challenge. The aim of this study was to identify demographic, substance use, and psychological factors that predict dropout from postdetoxification inpatient SUD treatment.

Materials and methods:

A total of 454 patients from 5 inpatient SUD centers in Central Norway were consecutively included in this naturalistic, prospective cohort study.

Results:

A total of 132 patients (28%) did not complete the planned treatment stay (dropped out). Cox regression analysis showed that higher levels of intrinsic motivation for changing personal substance use reduced the dropout risk (adjusted hazard ratio [adjHR]: 0.62, 95% confidence interval [CI]: 0.48-0.79). Higher levels of mental distress were associated with an increased risk for dropout (adjHR: 1.48, 95% CI: 1.11-1.97).

Conclusions:

The role of mental health and motivation in reducing dropout risk from inpatient SUD treatment should be targeted in future prospective intervention studies.