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Background: Independent medical evaluations are used to evaluate degree and reason for work disability, uncertainty around the functional status, and/or the employee's rehabilitation potential in several jurisdictions, but not in Norway. The main aim of this trial was to test the return to work effect of independent medical evaluation (IME) (summoning and consultation) compared to treatment as usual (TAU) in Norway, for workers who have been on continuous sick leave for 6 months., Methods: This was a pragmatic randomised controlled trial including all employees aged 18-65 years, sick-listed by their general practitioner and on full or partial sick leave for the past 26 weeks in Hordaland County, Norway in 2015/16. Trial candidates were drawn from a central register at the Norwegian Labour and Welfare Administration at 22 weeks of sick leave. Pregnant women, individuals with cancer or dementia diagnoses, those with secret address, employed by NAV or sick listed by the specialist health services were excluded. Separate regression analyses were conducted to investigate the "intention-to-treat" and "treatment on the treated" effects, using the ordinary least squares and instrumental variable methods, respectively., Results: After exemption based on predefined exclusion criteria, 5888 individuals were randomised to either IME (n = 2616) or TAU (n = 2599). The final intervention group constitutes 1698 individuals, of which 937 attended the IME consultation. No baseline differences were found between the IME and TAU group regarding gender, age, and previous sick leave. Individuals attending the IME were older than those who cancelled the appointment ((47/45), p = 0.006) and those who did not show up without cancelling ((47/42), p < 0.001). Mainly the IME physician agreed with the regular GP upon level of sick leave. In cases with different assessments, the difference tended to be towards a lower sick leave level. There were no intention to treat or treatment on the treated effect on days of sick leave after randomisation during follow up., Conclusions: Overall, the analyses showed no effect of IME on changes in sick leave for sick listed employees. This result was consistent for those who were offered an IME consultation (intention to treat) and those who undertook an IME consultation (treatment on the treated)., Trial Registration: ClinicalTirals.gov trial number NCT02524392 first registration 14.08.2015., (© 2022. The Author(s).)

Objective: To assess whether continuity of care (COC) with a general practitioner (GP) is associated with mortality and hospital admissions for older patients We argue that the conventional continuity measure may overestimate these associations. To better reflect COC as a GP quality indicator, we present an alternative, service-based measure., Design: Registry-based, population-level longitudinal cohort study., Setting: Linked data from Norwegian administrative healthcare registries, including 3989 GPs., Participants: 757 873 patients aged 60-90 years with ≥2 contacts with a GP during 2016 and 2017., Main Outcome Measure: All-cause emergency hospital admissions, emergency admissions for ambulatory care sensitive conditions, and mortality, in 2018., Results: We assessed COC using the conventional usual provider of care index (UPC patient ) and an alternative/supplementary index (UPC GP list ) based on the COC for all other patients enlisted with the same preferred GP.For both indices, the mean index score was 0.78. Our model controls for demographic and socioeconomic characteristics, prior healthcare use and municipality-fixed effects. Overall, UPC GP list shows a much weaker association between COC and the outcomes. For both indices, there is a negative relationship between COC and hospital admissions. A 0.2-point increase in the index score would reduce admissions for ambulatory care sensitive conditions by 8.1% (CI 7.1% to 9.1%) versus merely 1.9% (0.2% to 3.5%) according to UPC patient and UPC GP list , respectively. Using UPC GP list , we find that mortality is no longer associated with COC. There was greater evidence for an association between COC and all-cause admissions among patients with low education., Conclusions: A continuity measure based on each patient's contacts with own preferred GP may overestimate the importance of COC as a feature of the GP practice. An alternative, service-based measure of continuity could be suitable as a quality measure in primary healthcare. Facilitating continuity should be considered a health policy measure to reduce inequalities in health., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: It has been discussed whether the relationship between a patient on sick leave and his/her general practitioner (GP) is too close, as this may hinder the GP's objective evaluation of need for sick leave. Independent medical evaluation involves an independent physician consulting the patient. This could lead to new perspectives on sick leave and how to follow-up the patient., Methods/design: The current study is a randomized controlled trial in a Norwegian primary care context, involving an effect evaluation, a cost/benefit analysis, and a qualitative evaluation. Independent medical evaluation will be compared to treatment as usual, i.e., the physicians' and social insurance agencies' current management of long-term sick-listed patients. Individuals aged 18-65 years, sick listed by their GP and on full or partial sick leave for the past 6 months in Hordaland county will be included. Exclusion criteria are pregnancy, cancer, dementia or an ICD-10 diagnosis. A total sample of 3800 will be randomly assigned to either independent medical evaluation or treatment as usual. Official register data will be used to measure the primary outcome; change in sickness benefits at 7, 9 and 12 months. Sick listed in other counties will serve as a second control group, if appropriate under the "common trend" assumption., Discussion: The Norwegian effect evaluation of independent medical evaluation after 6 months sick leave is a large randomized controlled trial, and the first of its kind, to evaluate this type of intervention as a means of getting people back to work after long-term sickness absence., Trial Registration: ClinicalTrials.gov NCT02524392 . Registered June 23, 2015.

Background: Poor co-ordination and collaboration have been identified by many governments as a major and growing weakness of their health care systems. Better integrated care for the elderly individuals is one field of particular importance. In this study, we ask to what extent local authorities' social care services create cost externalities by prolonging hospital length of stay (LOS) because of inadequate service capacity and/or service quality., Methods: The data set is constructed by merging in-patient data from the Norwegian Patient Register with Statistics Norway's local authority variables for the period from 2007 to 2009. The sample includes ∼386 000 observations of in-patients aged ≥ 67 years. Using the quantile regression (QR) technique, we analyse the impact of social care services along the entire distribution of LOS. The QR estimates are compared with ordinary least square estimates (OLS). Patient variables in the analyses include age, gender and case-mix variables. Hospital and time-fixed effects are also controlled for variables., Results: More resources to the social care services give shorter LOS, and the QR analysis shows that resources matter more for patients in the long tail of the distribution compared with those in the lower quantiles. LOS is longer for patients with change of residence after discharge from hospital compared with those patients that do not change residence., Conclusions: Increased supply of social care services contributes to a reduction in aggregate societal costs of treatment and nursing of elderly patients by shortening comparatively costly hospital LOS.

Acknowledging the necessity of a division of labour between hospitals and social care services regarding treatment and care of patients with chronic and complex conditions, is to acknowledge the potential conflict of interests between health care providers. A potentially important conflict is that hospitals prefer comparatively short length of stay (LOS) at hospital, while social care services prefer longer LOS all else equal. Furthermore, inappropriately delayed discharges from hospital, i.e. bed blocking, is costly for society. Our aim is to discuss which factors that may influence bed blocking and to quantify bed blocking costs using individual Norwegian patient data, merged with social care and hospital data. The data allow us to divide hospital LOS into length of appropriate stay (LAS) and length of delay (LOD), the bed blocking period. We find that additional resources allocated to social care services contribute to shorten LOD indicating that social care services may exploit hospital resources as a buffer for insufficient capacity. LAS increases as medical complexity increases indicating hospitals incentives to reduce LOS are softened by considerations related to patients’ medical needs. Bed blocking costs constitute a relatively large share of the total costs of inpatient care.