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HELSEVEL-Gode og effektive helse-, omsorgs- og velferdstjenester

Health care services under pressure - Consequences for patient flows, efficiency and patient safety

Alternative title: Helsetjenester under press - konsekvenser for pasientflyt, effektivitet og pasientsikkerhet

Awarded: NOK 14.3 mill.

The purpose of this project is to examine consequences of pressure on the health care system. In published work from this project, we have used register data and qualitative interviews with general practitioners (GPs), staff at GP offices and health personnel in the specialised health services: - We looked at how the time of admission for hip fractures (season, weekday, hour of the day) is associated with 30-day mortality. International literature has largely revolved around patient safety related to weekend admissions versus work week admissions. This article showed minor differences in mortality on different days of hospitalization. However, the time of hospitalization showed large differences in mortality. - Concerns have been raised regarding the consequences of shorter length of hospital stays for hip fracture patients. We used the weekly variation in a hospital?s tendency to discharge patients as an instrument for hip fracture patients? risk of an expedited discharge. The results indicate that an expedited discharge of hip fracture patients increases mortality. - Crowding of patients in emergency departments is a well-known problem. We used detailed information about the time of admission, as well as the time of reported arrival to improve prediction on shorter time spans. - Long waiting times in emergency departments have been discussed as a possible risk factor for patient safety. In this study, prolonged emergency department stay was not associated with increased risk of death. However, we found a lower probability of being hospitalised with prolonged length of emergency department stay. - During periods when many patients are waiting for surgical procedures, hip fracture patients may have lower priority in the surgical queue. Lack of available resources can therefore lead to delayed operations and pose a risk to these patients. We found that in periods when the hospitals had more acute surgical patients than usual, the hip fracture patients had longer time for surgery and higher mortality. - Capacity pressure in the health services has been debated in recent years. We have examined how healthcare personnel experience and deal with pressure on capacity in the somatic specialist health services, as well as in the regular GP service. Although concerns about capacity pressure and patient safety emerged, there was no uniform description of the mechanisms around increased workload and capacity. - In a descriptive study, we examined contacts with the general practitioners in the year before a severe acute hospitalisation. The result showed that a large proportion of patients had contact with the GP in the year before hospitalisation. There was also a substantial group that had no contact with their GP in the month before admission - which may indicate a potential for prevention. - Patients may benefit from continuity of care by a personal physician general practitioner (GP), but there are few studies on consequences of a break in continuity of GP. This is challenging to study, since patients with e.g. complex health issues could be prone to change GP. We studied patients having GPs with a stable practice, but suddenly stopped meeting patients for at least two months. These patients had to seek help from other physicians in the period when their GP was unavailable. With this analytical design, we found that patients had somewhat fewer GP consultations and used a some more out-of-hours services in the period after their GP was unavailable. - We studied GPs working in out-of-hours services, and found considerable differences regarding use of hospital referrals for acute conditions. Patients under care of younger and female GPs had more unplanned hospital admissions immediately after an out-of-hours consultation, but effects on unplanned hospital admissions and costs within 30-days were moderate. The GPs prior tendency of using unplanned admissions was strongly associated with unplanned hospitalisations. - General practitioners (GPs) report increased workload, recruitment and retention problems. we investigated GP consultations in 2007-16 according to baseline health status. We observed a general increase in GP consultations over the study period, most prominent among the healthier groups.

In this project we will investigate the impact of system pressures on patient outcomes such as mortality and admissions and readmissions to hospitals. Providing adequate care to patients requires both coordination of care and balancing of capacity between different service levels. Reduced capacity in one part of the system may impair quality and also cause increased pressure in other parts of the system. These issues will be addressed in two parallel parts of the project. In Part 1, our aim is to analyse possible negative patient consequences of reduced length of stay due to non-medical factors. In Part 2 of the project, we analyse the association between general practitioners workload and clinical management of their list patients and their list patients risk of potentially avoidable hospital admissions. Our approach is methodologically ambitious in that we seek to establish not merely associations but causal links, and novel in that it combines data from different levels (primary and specialist health care) and sources (health survey and administrative data) and link these to outcome data such as cause specific mortality. The causal links following patient paths are difficult to assess, as the clinical indications for different paths are likely to be strongly associated with patient outcomes. In our project, we have two targeted approaches to avoid confounding by indication. Firstly we will use a case-only design in order to eliminate time-invariant confounding. That is, we will compare hospital wards and general practitioners with themselves, as the degree of for example capacity pressures varies over time. Next, we will apply an instrumental variable approach, which under certain assumptions has proven to be a fruitful way to assess the causal nature of potentially confounded associations. The project will employ two PhD candidates and two Post Docs.

Publications from Cristin

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HELSEVEL-Gode og effektive helse-, omsorgs- og velferdstjenester