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Integrated health care for people with chronic conditions. A policy brief.
No full text1-page key messages\ud
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* Uncoordinated care can affect the quality and efficiency of health care, access to care, participation in and satisfaction with care, and health outcomes for chronically ill patients. However, there is a paucity of data in Norway that provide a basis for estimating the size of the problem or clarifying the underlying reasons for inadequate coordination.\ud
* The impact of many changes in delivery, financial and governance arrangements that could be made to improve the coordination of care for people with chronic conditions is uncertain; evaluation is critical when such changes are made. \ud
* Components of the Chronic Care Model and disease management programs, alone or in combination, can improve quality of care, clinical outcomes and health care resource use, but the effects are not consistent and a number of obstacles may hinder their use.\ud
* The impacts of delivery arrangements that have been shown to be effective (e.g. patient education and motivational counselling, provider education, feedback, reminders, and multidisciplinary team work) are generally modest, but important. There is uncertainty about the impacts of other arrangements (e.g. care pathways, case management, and shared care).\ud
* Targeted financial incentives with the aim of achieving specific changes in how care is delivered probably influence discrete individual behaviours in the short run, but are less likely to influence sustained changes, and they can have unintended effects, including motivating unintended behaviours, distortions, gaming, cream skimming or cherry-picking, and bureaucratisation. Therefore, they require careful design and monitoring.\ud
* Similarly, changes in the basic payment methods that are used for both clinicians and institutions in order to offset the inherent limitations of each require careful design and monitoring. A long-term perspective with continual adjustments is more likely to be successful, than dramatic one-off changes.\ud
* There is not evidence to support any one governance model as being better than others. However, specific structures are likely needed at different levels to improve coordination:\ud
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o Clinical governance (healthcare professionals' accountability for quality of care) for both primary and secondary care\ud
o Boards at the local level that conduct detailed oversight and monitoring for both primary and secondary care\ud
o A regional board that coordinates different local networks in the region\ud
o A central governance structure that sets broad standards, which the regional and local boards are responsible to adhere to and implement\ud
* Consumer and stakeholder involvement in governance arrangements at all levels is a strategy for achieving better coordination of care and other health goals, as well as a goal in itself, but there is little evidence of how to best to achieve this.\ud
* Because there are multiple barriers to organisational and professional change, simple approaches to implementing change are unlikely to be effective, change is likely to occur incrementally and to require ongoing attention. \ud
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There are many tools that may be useful for implementing organisational changes, including analytic models, tools for assessing why change is needed, such as SWOT analysis, and tools for making changes, such as organisational development and project management. However, there is almost no evidence of their effectivenes
Brukererfaringer med poliklinikker for voksne i det psykiske helsevernet 2007. Institusjonsvise resultater
No full textVurdering av muligheten for en nasjonal brukererfaringsundersøkelse om fødselsomsorgen i Norge
No full textHelse- og omsorgsdepartementet arbeider med en stortingsmelding om svangerskaps-, fødsels- og barselomsorgen. I den forbindelse bestilte departementet i juni 2008 et hasteoppdrag fra Kunnskapssenteret om muligheten for å gjennomføre en nasjonal brukererfaringsundersøkelse innenfor fødselsomsorgen.\ud
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Internasjonalt er det gjennomført flere nasjonale undersøkelser om fødselsomsorgen, både i England, Skottland og Sverige. Erfaringene fra disse landene tilsier at det er mulig å gjennomføre undersøkelser med god kvalitet i denne gruppen.\ud
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Vi mener at det er fullt mulig å gjennomføre en nasjonal undersøkelse i Norge som ledd i de nasjonale brukererfaringsundersøkelsene, forutsatt at nødvendig utviklingsarbeid gjennomføres i forkant og at formelle tillatelser innvilges. Det er imidlertid viktig å presisere formålet med en nasjonal undersøkelse innenfor fødselsomsorgen i Norge. Presiseringen vil ha viktige praktiske, økonomiske og metodiske implikasjone
A 20-year prospective study of mortality and causes of death among hospitalized opioid addicts in Oslo.
No full textBACKGROUND: To study mortality rate and causes of death among all hospitalized opioid addicts treated for self-poisoning or admitted for voluntary detoxification in Oslo between 1980 and 1981, and to compare their mortality to that of the general population. METHODS: A prospective cohort study was conducted on 185 opioid addicts from all medical departments in Oslo who were treated for either self-poisoning (n = 93, 1980), voluntary detoxification (n = 75, 1980/1981) or both (n = 17). Their median age was 24 years; with a range from 16 to 41, and 53% were males. All deaths that had occurred by the end of 2000 were identified from the Central Population Register. Causes of death were obtained from Statistics Norway. Standardized mortality ratios (SMRs) were computed for mortality, in general, and in particular, for different causes of death. RESULTS: During a period of 20 years, 70 opioid addicts died (37.8%), with a standardized mortality ratio (SMR) equal to 23.6 (95% CI, 18.7-29.9). The SMR remained high during the whole period, ranging from 32.4 in the first five-year period, to 13.4 in the last five-year period. There were no significant differences in SMR between self-poisonings and those admitted for voluntarily detoxification. The registered causes of death were accidents (11.4%), suicide (7.1%), cancer (4.3%), cardiovascular disease (2.9%), other violent deaths (2.9%), other diseases (71.4%). Among the 50 deaths classified as other diseases, the category "drug dependence" was listed in the vast majority of cases (37 deaths, 52.9% of the total). SMRs increased significantly for all causes of death, with the other diseases group having the highest SMR; 65.8 (95% CI, 49.9-86.9). The SMR was 5.4 (95% CI, 1.3-21.5) for cardiovascular diseases, and 4.3 (95% CI, 1.4-13.5) for cancer. The SMR was 13.2 (95% CI, 6.6-26.4) for accidents, 10.7 (95% CI, 4.5-25.8) for suicides, and 28.6 (95% CI, 7.1-114.4) for other violent deaths. CONCLUSION: The risk of death among opioid addicts was significantly higher for all causes of death compared with the general population, implying a poor prognosis over a 20-year period for this young patient group
Predictors of mortality in HIV-infected patients starting antiretroviral therapy in a rural hospital in Tanzania.
No full textBACKGROUND: Studies of antiretroviral therapy (ART) programs in Africa have shown high initial mortality. Factors contributing to this high mortality are poorly described. The aim of the present study was to assess mortality and to identify predictors of mortality in HIV-infected patients starting ART in a rural hospital in Tanzania. METHODS: This was a cohort study of 320 treatment-naïve adults who started ART between October 2003 and November 2006. Reliable CD4 cell counts were not available, thus ART initiation was based on clinical criteria in accordance with WHO and Tanzanian guidelines. Kaplan-Meier models were used to estimate mortality and Cox proportional hazards models to identify predictors of mortality. RESULTS: Patients were followed for a median of 10.9 months (IQR 2.9-19.5). Overall, 95 patients died, among whom 59 died within 3 months of starting ART. Estimated mortality was 19.2, 29.0 and 40.7% at 3, 12 and 36 months, respectively. Independent predictors of mortality were severe anemia (hemoglobin <8 g/dL; adjusted hazard ratio [AHR] 9.20; 95% CI 2.05-41.3), moderate anemia (hemoglobin 8-9.9 g/dL; AHR 7.50; 95% CI 1.77-31.9), thrombocytopenia (platelet count <150 x 109/L; AHR 2.30; 95% CI 1.33-3.99) and severe malnutrition (body mass index <16 kg/m2; AHR 2.12; 95% CI 1.06-4.24). Estimated one year mortality was 55.2% in patients with severe anemia, compared to 3.7% in patients without anemia (P < 0.001). CONCLUSION: Mortality was found to be high, with the majority of deaths occurring within 3 months of starting ART. Anemia, thrombocytopenia and severe malnutrition were strong independent predictors of mortality. A prognostic model based on hemoglobin level appears to be a useful tool for initial risk assessment in resource-limited settings
Vaksiner mot humant papillomavirus (HPV). Etiske aspekter ved innføring av profylaktiske HPVvaksiner
No full textKEY MESSAGES: Ethical challenges with implementing prophylactic vaccines against human\ud
papilloma virus (HPV)\ud
Background: About 300 women get cervix cancer and about 100 die from cervix\ud
cancer every year in Norway. Cervic cancer is primarily caused by continuous infection\ud
with human papilloma virus (HPV), and over 120 strains of HPV have been\ud
identified. About 14 of these are are oncogenic. HPV-16 and HPV-18 can be found in\ud
about 70% of of the women with cervix cancer. Most HPV infections will cease by\ud
themselves, but where the infections persist, there is an increased risk for cellular\ud
changes. There exist vaccines against HPV 16/18, but there is yet no evicence that\ud
the vaccine is effective against cervical cancer. This has incited fierce debates on\ud
whether to introduce the HPV vaccine in national or statewide vaccination programs.\ud
This report aims at highlighting and discussing the moral aspects that are\ud
relevant for the decisionmaking process with regards to HPV vaccine.\ud
Method: The report uses a method developed for addressing ethical issues in health\ud
technology assessments (HTAs) that discusses central moral questions related to\ud
health interventions. The aim is not to give unequivocal answers to the questions,\ud
but rather to elucidate arguments and aspects that are important for decision makers\ud
and stake holders.\ud
Results: The potential utility of HPV 16/18 vaccination is considerable, but morally\ud
challenging, as the real impact of HPV vaccination on cervical cancer is not known,\ud
and the vaccine is costly. Vaccination is an intervention towards healthy people, calling\ud
for special attention, especially as there is conciderable uncertainty about its effects\ud
and side effects. It is challenging to assess future utility of potential prophylactic\ud
interventions against the utility of health interventions today. HPV vaccine of\ud
children is also challenging with respect to informed consent. Informing the public\ud
and potential persons to receive the vaccine appears to be a considerable challenge.\ud
Conclusion: HPV vaccination can potentially save 40 women from getting cervix\ud
cancer every year and 13 from dying, but there is no evidence for this, and vaccination\ud
is costly. That raises a series of morally challenging issues that are important to\ud
address when deciding whether to implement the vaccine or not (and how to implement\ud
it)
Pulmonary tuberculosis among people living with HIV/AIDS attending care and treatment in rural northern Tanzania.
No full textBACKGROUND: Tuberculosis is the commonest opportunistic infection and the number one cause of death in HIV/AIDS patients in developing countries. To address the extent of the tuberculosis HIV coinfection in rural Tanzania we conducted a cross sectional study including HIV/AIDS patients attending care and treatment clinic from September 2006 to March 2007. METHODS: Sputum samples were collected for microscopy, culture and drug susceptibility testing. Chest X-ray was done for those patients who consented. Blood samples were collected for CD4+ T cells count. RESULTS: The prevalence of tuberculosis was 20/233 (8.5%). Twenty (8.5%) sputum samples were culture positive. Eight of the culture positive samples (40%) were smear positive. Fifteen (75%) of these patients neither had clinical symptoms nor chest X-ray findings suggestive of tuberculosis. Nineteen isolates (95%) were susceptible to rifampicin, isoniazid, streptomycin and ethambutol (the first line tuberculosis drugs). One isolate (5%) from HIV/tuberculosis coinfected patients was resistant to isoniazid. No cases of multi- drug resistant tuberculosis were identified. CONCLUSION: We found high prevalence of tuberculosis disease in this setting. Chest radiograph suggestive of tuberculosis and clinical symptoms of fever and cough were uncommon findings in HIV/tuberculosis coinfected patients. Tuberculosis can occur at any stage of CD4+T cells depletion
The third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke.
No full textABSTRACT: BACKGROUND: Intravenous recombinant tissue plasminogen activator (rt-PA) is approved for use in selected patients with ischaemic stroke within 3 hours of symptom onset. IST-3 seeks to determine whether a wider range of patients may benefit. DESIGN: International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rt-PA in acute ischaemic stroke. Suitable patients must be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracerebral haemorrhage. With 1000 patients, the trial can detect a 7% absolute difference in the primary outcome. With3500 patients, it can detect a 4.0% absolute benefit & with 6000, (mostly treated between 3 & 6 hours), it can detect a 3% benefit. TRIAL PROCEDURES: Patients are entered into the trial by telephoning a fast, secure computerised central randomisation system or via a secure web interface. Repeat brain imaging must be performed at 24-48 hours. The scans are reviewed 'blind' by expert readers. The primary measure of outcome is the proportion of patients alive and independent (Modified Rankin 0-2) at six months (assessed via a postal questionnaire mailed directly to the patient). Secondary outcomes include: events within 7 days (death, recurrent stroke, symptomatic intracranial haemorrhage), outcome at six months (death, functional status, EuroQol). TRIAL REGISTRATION: ISRCTN25765518
How should the impact of different presentations of treatment effects on patient choice be evaluated? A pilot randomized trial.
No full textBACKGROUND: Different presentations of treatment effects can affect decisions. However, previous studies have not evaluated which presentations best help people make decisions that are consistent with their own values. We undertook a pilot study to compare different methods for doing this. METHODS AND FINDINGS: We conducted an Internet-based randomized trial comparing summary statistics for communicating the effects of statins on the risk of coronary heart disease (CHD). Participants rated the relative importance of treatment consequences using visual analogue scales (VAS) and category rating scales (CRS) with five response options. We randomized participants to either VAS or CRS first and to one of six summary statistics: relative risk reduction (RRR) and five absolute measures of effect: absolute risk reduction, number needed to treat, event rates, tablets needed to take, and natural frequencies (whole numbers). We used logistic regression to determine the association between participants' elicited values and treatment choices. 770 participants age 18 or over and literate in English completed the study. In all, 13% in the VAS-first group failed to complete their VAS rating, while 9% of the CRS-first group failed to complete their scoring (p = 0.03). Different ways of weighting the elicited values had little impact on the analyses comparing the different presentations. Most (51%) preferred the RRR compared to the other five summary statistics (1% to 25%, p = 0.074). However, decisions in the group presented the RRR deviated substantially from those made in the other five groups. The odds of participants in the RRR group deciding to take statins were 3.1 to 5.8 times that of those in the other groups across a wide range of values (p = 0.0007). Participants with a scientific background, who were more numerate or had more years of education were more likely to decide not to take statins. CONCLUSIONS: Internet-based trials comparing different presentations of treatment effects are feasible, but recruiting participants is a major challenge. Despite a slightly higher response rate for CRS, VAS is preferable to avoid approximation of a continuous variable. Although most participants preferred the RRR, participants shown the RRR were more likely to decide to take statins regardless of their values compared with participants who were shown any of the five other summary statistics. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN85194921
Evidence-informed health policy 1 - Synthesis of findings from a multi-method study of organizations that support the use of research evidence.
No full textABSTRACT: BACKGROUND: Organizations have been established in many countries and internationally to support the use of research evidence by producing clinical practice guidelines, undertaking health technology assessments, and/or directly supporting the use of research evidence in developing health policy on an international, national, and state or provincial level. Learning from these organizations can reduce the need to 'reinvent the wheel' and inform decisions about how best to organize support for such organizations, particularly in low- and middle-income countries (LMICs). METHODS: We undertook a multi-method study in three phases - a survey, interviews, and case descriptions that drew on site visits - and in each of the second and third phases we focused on a purposive sample of those involved in the previous phase. We used the seven main recommendations that emerged from the advice offered in the interviews to organize much of the synthesis of findings across phases and methods. We used a constant comparative method to identify themes from across phases and methods. RESULTS: Seven recommendations emerged for those involved in establishing or leading organizations that support the use of research evidence in developing health policy: 1) collaborate with other organizations; 2) establish strong links with policymakers and involve stakeholders in the work; 3) be independent and manage conflicts of interest among those involved in the work; 4) build capacity among those working in the organization; 5) use good methods and be transparent in the work; 6) start small, have a clear audience and scope, and address important questions; and 7) be attentive to implementation considerations, even if implementation is not a remit. Four recommendations emerged for the World Health Organization (WHO) and other international organizations and networks: 1) support collaborations among organizations; 2) support local adaptation efforts; 3) mobilize support; and 4) create global public goods. CONCLUSION: This synthesis of findings from a multi-method study, along with the more detailed findings from each of the three phases of the study (which are reported in the three following articles in the series), provide a strong basis on which researchers, policymakers, international organizations (and networks) like WHO can respond to the growing chorus of voices calling for efforts to support the use of research evidence in developing health policy