General practitioners’ perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Background Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL. Methods We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews. Results GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL. Conclusion Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel.publishedVersio

Transfer Pricing in Hospitals - Investigating the Need and Possible Methods of Transfer Pricing in Norwegian Hospitals

The aim of this master thesis is to investigate if there is a need for transfer pricing in Norwegian hospitals, and which transfer pricing methods should be considered if such a need exists. As divisions in Norwegian hospitals are not always committed to reimburse goods or services provided by other divisions, some divisions have the opportunity to increase production, and potentially improve their operating profit, without compensating other divisions taking part in production. As internal firm inefficiency may result, this serves as the background for the thesis work. The thesis first builds a theoretical framework from literature findings on transfer pricing to identify both potential advantageous, and disadvantageous arguments of transfer pricing. In addition, the thesis identifies and discusses available transfer pricing methods. A qualitative research design is chosen, and semi-structured interviews used to explore the theoretical framework and choice of transfer pricing method. Three potential advantages of transfer pricing are identified; a more well-functioning internal market (the economic argument), improved quality (the organizational argument) and improved monitoring and control due to increased quality of data (the evaluational argument). One potential disadvantage of transfer pricing is identified: the cost of developing, implementing and operating the transfer pricing system (the functional argument). The main conclusion of the thesis is that the decision to implement a transfer pricing system in a hospital will depend on the sum of the relevant advantageous and disadvantageous arguments of transfer pricing, and that the advantageous economic argument and disadvantageous functional argument are the main arguments affecting this decision. In addition, it is concluded that a transfer pricing system must involve a mechanism that secures the longevity of the economic argument. Last, the thesis concludes that actual cost or standard cost should be the preferred transfer pricing method in the investigated hospital, but that the choice of transfer pricing method is less important than securing the longevity of the economic argument

A Qualitative Study on Distributed Leadership in Integrated Care: Exploring the Experiences of Elderly Multimorbid Patients with GP Collaboration

Objective: This study explores how the collaboration between elderly multimorbid patients and general practitioners contributes to the patient’s experience of integrated care in the municipality. The research also investigates whether the municipality’s integrative mechanisms creating integrated care can be understood as distributed leadership. Method: In this qualitative study, we conducted a thematic analysis of semi-structured interviews with twenty elderly multimorbid patients living at home and their general practitioners. Results: Analysis of patients’ and general practitioners’ experience of healthcare service characterized by collective efforts identified four themes: 1) an impression of collective processes as difficult for patients to access and influence; 2) that the fluidity and location of leadership is dependent on the individual patient and his or her health condition; 3) that collective implementation of healthcare services is separated in time, geography and between organizations; and 4) that patients experience individual healthcare workers as specialized and unable to support the medical and holistic goals of the collective. The Direction, Alignment, and Commitment or DAC framework, is used to investigate the capabilities of the collective. Conclusion: To promote distributed leadership and create a patient experience of integrated care in the municipality, healthcare organizations must develop collective processes that enhance patient participation to a greater extent. General practitioners and other healthcare personnel should be encouraged to play a more central role in solving elderly multimorbid patients’ healthcare needs in the municipality.publishedVersio

General practitioners’ perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Background Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL. Methods We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews. Results GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL. Conclusion Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel

General practitioners’ perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Background Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL. Methods We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews. Results GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL. Conclusion Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel

Older Adults’ Experiences With Participation and eHealth in Care Coordination: Qualitative Interview Study in a Primary Care Setting

BackgroundOwing to the demographic changes in the elderly population worldwide, delivering coordinated care at home to multimorbid older adults is of great importance. Older adults living with multiple chronic conditions need information to manage and coordinate their care. eHealth can be effective for gaining sufficient information, communicating, and self-managing chronic conditions. However, incorporating older adults’ health preferences and ensuring active involvement remain challenging. More knowledge is needed to ensure successful participation and eHealth use in care coordination. ObjectiveThis study aimed to explore multimorbid older adults’ experiences with participation and eHealth in care coordination with general practitioners (GPs) and district nurses (DNs). MethodsThe study had a qualitative explorative approach. Data collection included semistructured interviews with 20 older adults with multimorbidity receiving primary care services from their GPs and DNs. The participants were included by their GPs or nurses at a local intermunicipal acute inpatient care unit. The data analysis was guided by systematic text condensation. ResultsWe identified 2 categories: (1) older adults in charge of and using eHealth in care coordination, and (2) older adults with a loss of control in care coordination. The first category describes how communication with GPs and DNs can facilitate participation, the importance of managing own medication, and how eHealth can support older adults’ information needs. The second category focuses on older adults who depend on guidance and help from their GPs and DNs to manage their health, describing how a lack of capacity and system support to be involved makes these adults lose control of their care coordination. ConclusionsBeing in charge of care coordination is important for older multimorbid adults. The results show that older adults are willing to use eHealth to be informed and to seek information, which ensures high levels of participation in care coordination. Future research should investigate how older adults can be involved in electronic information sharing with health care providers

The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years)

Purpose: Very old critical ill patients are a rapid expanding group in the ICU. Indications for admission, triage criteria and level of care are frequently discussed for such patients. However, most relevant outcome studies in this group frequently find an increased mortality and a reduced quality of life in survivors. The main objective was to study the impact of frailty compared with other variables with regards to short-term outcome in the very old ICU population. Methods: A transnational prospective cohort study from October 2016 to May 2017 with 30 days follow-up was set up by the European Society of Intensive Care Medicine. In total 311 ICUs from 21 European countries participated. The ICUs included the first consecutive 20 very old (≥ 80 years) patients admitted to the ICU within a 3-month inclusion period. Frailty, SOFA score and therapeutic procedures were registered, in addition to limitations of care. For measurement of frailty the Clinical Frailty Scale was used at ICU admission. The main outcomes were ICU and 30-day mortality and survival at 30 days. Results: A total of 5021 patients with a median age of 84 years (IQR 81–86 years) were included in the final analysis, 2404 (47.9%) were women. Admission was classified as acute in 4215 (83.9%) of the patients. Overall ICU and 30-day mortality rates were 22.1% and 32.6%. During ICU stay 23.8% of the patients did not receive specific ICU procedures: ventilation, vasoactive drugs or renal replacement therapy. Frailty (values ≥ 5) was found in 43.1% and was independently related to 30-day survival (HR 1.54; 95% CI 1.38–1.73) for frail versus non-frail. Conclusions: Among very old patients (≥ 80 years) admitted to the ICU, the consecutive classes in Clinical Frailty Scale were inversely associated with short-term survival. The scale had a very low number of missing data. These findings provide support to add frailty to the clinical assessment in this patient group. Trial registration: ClinicalTrials.gov (ID: NCT03134807)

Sepsis at ICU admission does not decrease 30-day survival in very old patients: a post-hoc analysis of the VIP1 multinational cohort study

Background: The number of intensive care patients aged ≥ 80 years (Very old Intensive Care Patients; VIPs) is growing. VIPs have high mortality and morbidity and the benefits of ICU admission are frequently questioned. Sepsis incidence has risen in recent years and identification of outcomes is of considerable public importance. We aimed to determine whether VIPs admitted for sepsis had different outcomes than those admitted for other acute reasons and identify potential prognostic factors for 30-day survival. Results: This prospective study included VIPs with Sequential Organ Failure Assessment (SOFA) scores ≥ 2 acutely admitted to 307 ICUs in 21 European countries. Of 3869 acutely admitted VIPs, 493 (12.7%) [53.8% male, median age 83 (81-86) years] were admitted for sepsis. Sepsis was defined according to clinical criteria; suspected or demonstrated focus of infection and SOFA score ≥ 2 points. Compared to VIPs admitted for other acute reasons, VIPs admitted for sepsis were younger, had a higher SOFA score (9 vs. 7, p < 0.0001), required more vasoactive drugs [82.2% vs. 55.1%, p < 0.0001] and renal replacement therapies [17.4% vs. 9.9%; p < 0.0001], and had more life-sustaining treatment limitations [37.3% vs. 32.1%; p = 0.02]. Frailty was similar in both groups. Unadjusted 30-day survival was not significantly different between the two groups. After adjustment for age, gender, frailty, and SOFA score, sepsis had no impact on 30-day survival [HR 0.99 (95% CI 0.86-1.15), p = 0.917]. Inverse-probability weight (IPW)-adjusted survival curves for the first 30 days after ICU admission were similar for acute septic and non-septic patients [HR: 1.00 (95% CI 0.87-1.17), p = 0.95]. A matched-pair analysis in which patients with sepsis were matched with two control patients of the same gender with the same age, SOFA score, and level of frailty was also performed. A Cox proportional hazard regression model stratified on the matched pairs showed that 30-day survival was similar in both groups [57.2% (95% CI 52.7-60.7) vs. 57.1% (95% CI 53.7-60.1), p = 0.85]. Conclusions: After adjusting for organ dysfunction, sepsis at admission was not independently associated with decreased 30-day survival in this multinational study of 3869 VIPs. Age, frailty, and SOFA score were independently associated with survival

Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit

PURPOSE: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU. METHODS: This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up. RESULTS: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries. CONCLUSIONS: The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country. TRIAL REGISTRATION: ClinicalTrials.gov (ID: NTC03134807)