Does expansion of municipal services lead to reduced use of secondary health care? Which effects does the level and composition of health care services have on costs, resource use and the patients survival? The objective is to evaluate the effects of the three main measures in the Norwegian Coordination Reform: a) municipal cofounding of specialist care, b) municipal responsibility for patients ready for discharge and c) the implementation of the municipal acute bed units. Also other measures to coordinate care that are in underdevelopment within four metropolitan areas will be evaluated.
The main innovation within the project is to link data from the national patient registers, registers covering the GPs and registers covering long term care. Data covers Copenhagen, Helsinki,Oslo and Stockholm for the period 2009-2014.
Moger and Hagen (2017) analysed incidents, pathways, use of services, 30-days readmission rates and 30/365-days mortality for patients diagnosed with heart infarction, stroke and hip fracture, for Oslo in total as well as for each of the boroughs before and after the reform. There was a small reduction in the use of home nursing for all three patient groups when compared to the period before the coordination reform. The time to first contact with the GP for patients living at home was reduced, as intended, but still above the target of 14 days. There were only small differences in use of services, readmissions and mortality for all patient groups between the boroughs after we had controlled for age, gender, comorbidities and ADL-score. Thus, the level of services seems to be allocated adequately between different parts of the city. Also differences in mortality show small variation after control for relevant risk factors.
Häkkinen, Hagen and Moger (2018) analysed whether integration of care between primary and specialist health care services affected the quality in the treatment for hip fracture patients in Helsinki and Oslo in the period 2009-2014. Before the coordination reform the length of the hospital stays was longer in Oslo than in Helsinki. More patients were also discharged to home in Oslo and the patients discharged to home got more services than those in Helsinki. In Helsinki more patients were discharged to institutions. After the coordination reform more patients in Oslo was discharged to institutions/nursing homes meaning that the length of stay in institutions (hospital + nursing homes) was comparable to the LOS before the reform. One year costs went down in both cities during the period, but more in Helsinki than in Oslo. There was modestly increasing trend in 30- day mortality after the reform in Oslo paralleled by a decreasing trend in the Helsinki area.
There are two main challenges related to the evaluation of the effects of the Norwegian coordination reform. The first is that the reform is implemented simultaneously in all Norwegian Municipalities. This makes it difficult to establish causal relationsh ips between the reform and its effects since other events and trends most possibly will be strongly correlated with the implementation. Secondly, there are currently restrictions on the use of municipal data from the national IPLOS-register (a database de scribing needs and use of long term care services) that makes it impossible to link it with hospital registers. This project will handle these two problems by a well specified comparative design where Helsinki and Stockholm serves as a reference units in the analyses and by linking City of Oslos Gerica- register to the hospital registers. The Gerica-register includes similar variable as the IPLOS-register and is not delimited by restrictions on links to other registers.
Helsinki and Stockholm are not ra ndom choices. First, the Finnish health care system differs from the Norwegian and the Swedish in the way that specialist healthcare services are provided by municipality-owned hospital districts instead of state-owned (Norway) or county-owned (Sweden) ho spitals. The hospital districts are with exception of some services in university hospitals, fully financed by the municipalities. In many ways the main elements of the Norwegian Coordination Reform can be regarded as steps towards the Finnish model. Seco nd, both Finland and Sweden have developed local health centres that offer a comprehensive mix of primary health care services, including local acute services, that now are under development in Norway. Third, similar data from long term care, primary care physicians and hospitals that are available in Oslo will be made available from Helsinki and neighbouring municipalities. Altogether these three elements will make it possible to establish an experimental design.