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Iešsorbmen lea fuopmášahtti servodat- ja álbmotdearvvašvuođaváttisvuohta globálalaččat ja sisriikkalaččat. Iešsorbmen dáhpáhuvvá maiddái sámi servodagain gos ollu gilit ja bearrašat leat bahuid vahágahtton. Eará sániiguin, Sámis leat ollu oapmahaččat maŋŋá iešsorbmema. Dát kapihtal čalmmustahttá iešguđetlágán hástalusaid maid oapmahaččat sámi guovlluin vásihit go deaivvadit báikkálaš veahkehanásahusain. Kapihttalis digaštallat hástalusaid čadnon dasa go galgá veahki oažžut smávva servodagažiin ja veahkkeásahusa váilevaš ipmárdusa. Loahpas problematiseret makkár mearkkašupmi lea máhtus ja ipmárdusas oapmahaččaid dilálašvuođa birra ja dan kultuvrralaš konteavsttas mas son eallá., Selvmord er et betydelig samfunns- og folkehelseproblem globalt og nasjonalt. Selvmord forekommer også i samiske samfunn hvor flere bygder og familier er hardt rammet. Det er med andre ord mange etterlatte ved selvmord i Sápmi. Dette kapitlet setter søkelys på ulike utfordringer som etterlatte i samiske områder kan oppleve i møte med det lokale hjelpeapparatet. I kapitlet diskuteres utfordringer knyttet til det å motta hjelp i små samfunn og manglende tillit til hjelpeapparatet. Avslutningsvis problematiseres betydningen av å ha kunnskap og forståelse for etterlattes situasjon og den kulturelle konteksten han eller hun lever i.

Background: Technology support and patient-centred care are the new mantra for health care programmes in Western societies. While few argue with the overarching philosophy of patient-centred care nor with the potential of information technologies, there is less agreement on how to make them a reality in everyday clinical practice. In this paper, we investigate how individual health care providers at four innovation arenas in Scandinavia experienced the implementation of technology-supported person-centred care for persons with long-term care needs by using the new analytical framework Nonadoption, Abandonment and challenges to the Scale-Up, Spread, and Sustainability of health and care technologies (NASSS). We also discuss the usability and sensitivity of the NASSS framework for those seeking to plan, implement and evaluate technology-supported health care programmes. This study is part of an interdisciplinary research and development project called Patients and Professionals in Partnership (2016 - 2020). It originates at one of nine work packages in this project.Method: The main data consist of ethnographic field observations at the four innovations arenas and 29 interviews with involved health care providers. To ensured continuous updates and status on work at the four innovation arenas, we have also participated in a total of six annual networks meeting arrange by the project. Results: While the NASSS framework is very useful indeed for identifying and communicating challenges with adoption and spread of technology-supported person-centred- care initiatives, we find it less sensitive towards capturing the dedication, enthusiasm and passion for care transformation that we found among the health care providers in our study. When it comes to technology-supported person-centred care, the point of no return has passed for the involved health care providers. To them, it is already a definite part of the future of healthcare services. How to overcome barriers and obstacles is pragmatically approached. Conclusion: Increased knowledge about the health care providers and their visions as potential assets for care transformation might be critical for those seeking to plan, implement and evaluate technology-supported health care programmes.

Background Technology support and person-centred care are the new mantra for healthcare programmes in Western societies. While few argue with the overarching philosophy of person-centred care or the potential of information technologies, there is less agreement on how to make them a reality in everyday clinical practice. In this paper, we investigate how individual healthcare providers at four innovation arenas in Scandinavia experienced the implementation of technology-supported person-centred care for people with long-term care needs by using the new analytical framework nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability (NASSS) of health and care technologies. We also discuss the usability and sensitivity of the NASSS framework for those seeking to plan, implement, and evaluate technology-supported healthcare programmes. This study is part of an interdisciplinary research and development project called Patients and Professionals in Partnership (2016–2020). It originates at one of ten work packages in this project. Method The main data consist of ethnographic field observations at the four innovation arenas and 29 interviews with involved healthcare providers. To ensure continuous updates and status on work in the four innovation arenas, we have also participated in a total of six annual network meetings arranged by the project. Results While the NASSS framework is very useful for identifying and communicating challenges with the adoption and spread of technology-supported person-centred care initiatives, we found it less sensitive towards capturing the dedication, enthusiasm, and passion for care transformation that we found among the healthcare providers in our study. When it comes to technology-supported person-centred care, the point of no return has passed for the involved healthcare providers. To them, it is already a definite part of the future of healthcare services. How to overcome barriers and obstacles is pragmatically approached. Conclusion Increased knowledge about healthcare providers and their visions as potential assets for care transformation might be critical for those seeking to plan, implement, and evaluate technology-supported healthcare programmes.

Background The Patient-Centered Team (PACT) focuses on the transitional phase between hospital and primary care for older patients in Northern Norway with complex and long-term needs. PACT emphasizes a person-centered care approach whereby the sharing of power and the patient’s response to “What matters to you?” drive care decisions. However, during the COVID-19 pandemic, videoconferencing was the only option for assessing, planning, coordinating, and performing treatment and care. Objective The aim of this study is to report the experience of the PACT multidisciplinary health care team in shifting rapidly from face-to-face care to using videoconferencing for clinical and collaborative services during the initial phase of the COVID-19 pandemic. This study explores how PACT managed to maintain person-centered care under these conditions. Methods This case study takes a qualitative approach based on four semistructured focus group interviews carried out in May and June 2020 with 19 PACT members and leaders. Results The case study illustrates that videoconferencing is a good solution for many persons with complex and long-term needs and generates new opportunities for interaction between patients and health care personnel. Persons with complex and long-term needs are a heterogeneous group, and for many patients with reduced cognitive capacity or hearing and vision impairment, the use of videoconferencing was challenging and required support from relatives or health care personnel. The study shows that using videoconferencing offered an opportunity to use health care personnel more efficiently, reduce travelling time for patients, and improve the information exchange between health care levels. This suggests that the integration of videoconferencing contributed to the preservation of the person-centered focus on care during the COVID-19 pandemic. There was an overall agreement in PACT that face-to-face care needed to be at the core of the person-centered care approach; the main use of videoconferencing was to support follow-up and coordination. Conclusions The COVID-19 pandemic and the rapid adoption of digital care have generated a unique opportunity to continue developing a health service to both preserve and improve the person-centered care approach for persons with complex and long-term needs. This creates demand for overall agreements, including guidelines and procedures for how and when to use videoconferencing to supplement face-to-face treatment and care. Implementing videoconferencing in clinical practice generates a need for systematic training and familiarization with the equipment and technology as well as for an extensive support organization. Videoconferencing can then contribute to better preparing health care services for future scenarios.

BACKGROUND The Patient-Centered Team (PACT) focuses on the transitional phase between hospital and primary care for older patients in Northern Norway with complex and long-term needs. PACT emphasizes a person-centered care approach whereby the sharing of power and the patient’s response to “What matters to you?” drive care decisions. However, during the COVID-19 pandemic, videoconferencing was the only option for assessing, planning, coordinating, and performing treatment and care. OBJECTIVE The aim of this study is to report the experience of the PACT multidisciplinary health care team in shifting rapidly from face-to-face care to using videoconferencing for clinical and collaborative services during the initial phase of the COVID-19 pandemic. This study explores how PACT managed to maintain person-centered care under these conditions. METHODS This case study takes a qualitative approach based on four semistructured focus group interviews carried out in May and June 2020 with 19 PACT members and leaders. RESULTS The case study illustrates that videoconferencing is a good solution for many persons with complex and long-term needs and generates new opportunities for interaction between patients and health care personnel. Persons with complex and long-term needs are a heterogeneous group, and for many patients with reduced cognitive capacity or hearing and vision impairment, the use of videoconferencing was challenging and required support from relatives or health care personnel. The study shows that using videoconferencing offered an opportunity to use health care personnel more efficiently, reduce travelling time for patients, and improve the information exchange between health care levels. This suggests that the integration of videoconferencing contributed to the preservation of the person-centered focus on care during the COVID-19 pandemic. There was an overall agreement in PACT that face-to-face care needed to be at the core of the person-centered care approach; the main use of videoconferencing was to support follow-up and coordination. CONCLUSIONS The COVID-19 pandemic and the rapid adoption of digital care have generated a unique opportunity to continue developing a health service to both preserve and improve the person-centered care approach for persons with complex and long-term needs. This creates demand for overall agreements, including guidelines and procedures for how and when to use videoconferencing to supplement face-to-face treatment and care. Implementing videoconferencing in clinical practice generates a need for systematic training and familiarization with the equipment and technology as well as for an extensive support organization. Videoconferencing can then contribute to better preparing health care services for future scenarios.

Improved treatment methods for cancer are increasing the number of survivals in Norway. In turn, the group of people struggling with late effects after the treatment is growing. Late effects could be physical, psychological or existential conditions caused by treatment or the experience of illness. This qualitative study explores health-seeking actions among nine Norwegian people with cancer, and how they shape their trajectories to healing. Various health-seeking actions were identified through content analysis, and categorized as conventional, CAM, self-care, religious coping and traditional healing. Medical pluralism particularly flourished in the aftermath of cancer. We found that the phenomenon is characterized by: 1) implementation of contradicting models of reality and making pragmatic choices, 2) continuity and change of health seeking actions, 3) medical pluralism as a process, and 4) increased use of CAM and self-care to improve health and well-being in situations where the conventional care system has few available treatment options. To support people with long-term conditions, we need to know how they choose and make sense of their health-seeking activities. We argue that trajectories to healing are dynamic and shaped by people making choices. This process could be understood in greater depth by applying the concept of medical landscapes.

Health care service provision of individualised treatment to an ageing population prone to chronic conditions and multimorbidities is threatened. There is a need for digitally supported care, that is, (1) person-centred, (2) integrated, and (3) proactive. The research project 3P, Patients and Professionals in Productive Teams, aimed to validate and verify the prerequisites for health care systems run with patient-centred service models. This paper presents an explorative study of the digital support of a cross-organisational health care team in Norway, providing services to elderly frail people with multimorbidities in hospital discharge transition. Qualitative research methods were employed, with interviews and observations to map and evaluate the information flow and the digital support of collaborative work across organisations. The evaluation showed a lacking interoperability between the digital systems and a limited support for cross-organisational teamwork, causing raised manual efforts to maintain the information flow. Tools for coordination and planning across organisations were lacking. To enhance the situation, principles for a cloud-based health portal are proposed with a shared workspace, teamwork functionality for cross-organisational health care teams, and automatic back-end synchronisation of stored information. The main implications of this paper lie in the proposed principles which are transferable to a multitude of clinical contexts, where ad-hoc based access to shared medical information is of importance for decision-making and life-saving treatment.

BackgroundPerson-centred care (PCC) focusing on personalised goals and care plans derived from “What matters to you?” has an impact on single disease outcomes, but studies on multi-morbid elderly are lacking. Furthermore, the combination of PCC, Integrated Care (IC) and Pro-active care are widely recognised as desirable for multi-morbid elderly, yet previous studies focus on single components only, leaving synergies unexplored. The effect of a synergistic intervention, which implements 1) Person-centred goal-oriented care driven by “What matters to you?” with 2) IC and 3) pro-active care is unknown.MethodsInspired by theoretical foundations, complexity science, previous health service research and a patient-driven evaluation of care quality, we designed the Patient-Centred Team (PACT) intervention across primary and secondary care. The PACT team collaborate with the patient to make and deliver a person-centred, integrated and proactive multi-morbidity care-plan. The control group receives conventional care. The study design is a pragmatic six months prospective, controlled clinical trial based on hospital electronic health record data of 439 multi-morbid frail elderly at risk for emergency (re) admissions referred to PACT and 779 propensity score matched controls in Norway, 2014–2016. Outcomes are emergency admissions, the sum of emergency inpatient bed days, 30-day readmissions, planned and emergency outpatient visits and mortality at three and six months follow-up.ResultsThe Rate Ratios (RR) for emergency admissions was 0,9 (95%CI: 0,82-0,99), for sum of emergency bed days 0,68 (95%CI:0,52-0,79) and for 30-days emergency readmissions 0,72 (95%CI: 0,41-1,24). RRs were 2,3 (95%CI: 2,02-2,55) and 0,9 (95%CI: 0,68-1,20) for planned and emergency outpatient visits respectively. The RR for death at 3 months was 0,39 (95% CI: 0,22-0,70) and 0,57 (95% CI: 0,34-0,94) at 6 months.ConclusionCompared with propensity score matched controls, the care process of frail multi-morbid elderly who received the PACT intervention had a reduced risk of high-level emergency care, increased use of low-level planned care, and substantially reduced mortality risk. Further study of process differences between groups is warranted to understand the genesis of these results better.Trial registrationClinicalTrials.gov (identifier:NCT02541474), registered Sept 2015.

Source at https://doi.org/10.1186/s12913-018-3246-z. © The Author(s). 2018 Background: Person-Centered Integrated Care (PC-IC) is believed to improve outcomes and experience for persons with multiple long-term and complex conditions. No broad consensus exists regarding how to capture the patient-experienced quality of PC-IC. Most PC-IC evaluation tools focus on care events or care in general. Building on others’ and our previous work, we outlined a 4-stage goal-oriented PC-IC process ideal: 1) Personalized goal setting 2) Care planning aligned with goals 3) Care delivery according to plan, and 4) Evaluation of goal attainment. We aimed to explore, apply, refine and operationalize this quality of care framework. Methods: This paper is a qualitative evaluative review of the individual Patient Pathways (iPP) experiences of 19 strategically chosen persons with multimorbidity in light of ideals for chronic care. The iPP includes all care events, addressing the persons collected health issues, organized by time. We constructed iPPs based on the electronic health record (from general practice, nursing services, and hospital) with patient follow-up interviews. The application of the framework and its refinement were parallel processes. Both were based on analysis of salient themes in the empirical material in light of the PC-IC process ideal and progressively more informed applications of themes and questions. Results: The informants consistently reviewed care quality by how care supported/ threatened their long-term goals. Personal goals were either implicit or identified by “What matters to you?” Informants expected care to address their long-term goals and placed responsibility for care quality and delivery at the system level. The PC-IC process framework exposed system failure in identifying long-term goals, provision of shared long-term multimorbidity care plans, monitoring of care delivery and goal evaluation. The PC-IC framework includes descriptions of ideal care, key questions and literature references for each stage of the PC-IC process. This first version of a PC-IC process framework needs further validation in other settings. Conclusion: Gaps in care that are invisible with event-based quality of care frameworks become apparent when evaluated by a long-term goal-driven PC-IC process framework. The framework appears meaningful to persons with multimorbidity.

Aim: In this workshop we will present ideas and discuss how to make health service improvements that reach for the Quadruple Aim. Background: Despite large efforts and many studies, the research community still does not understand how to reach Berwick's and Bodenheimer’s quadruple aims for care (better patient experience, health and function, cost-benefit ratio and professional experience), with any degree of predictability (1). In a recent review on this topic, we found that interventions tend to reflect a reductionist paradigm, which forces care workers into standardized and narrowly focused interventions also for complex problems (2). There was a lack of studies that build on theoretical models for health care, complexity theory and change management set in complex adaptive systems. We, the authors, build on decades of experience in large scale care transformation processes in health care. We have combined technical and social work practice innovation. Our efforts include close collaboration with patient partners, front line health professionals, decision makers and e-health service providers. Our current working hypothesis is that complex health service improvements will yield predictable outcomes, when researchers 1) fully understand the nature of synergistic digitally supported, person-centered, integrated and proactive care 2) tailor interventions to local strengths and weaknesses, 3) add a continuous formative evaluation which is fed back into the process, and 4) include all the areas of the quadruple aim in the final summative evaluation. Target audience: Stakeholders of health service improvement like patients, practitioners, researcher and others interested in diving into the complexity of health service improvement. Take away: Insights into the structuring and practical implementation of health service improvements towards the quadruple aim. Format 90 min workshop: 30 min: Berntsen GKR: A brief overview of the literature of studies reaching for the Quadruple Aim, with emphasis on : • The active ingredients: Digitally supported Person-centered, integrated and proactive care • The design of the implementation process in a local context • The possible role of evaluation in change management. 30 min: Cafe dialogue in breakout sessions Each group will discuss all the questions below. However, the four groups will start with “their” question, and then move on to the other questions in the session. • Host: Gro Berntsen: What do the active ingredients person-centered, integrated and proactive care really mean? • Host: Aslak Steinsbekk and Anders Grimsmo- How do we design locally tailored implementation processes? • Host: Berglind Smaradottir and Espen Nordheim : What kind of digital tools are essential to support the active ingredients? • Host: Line Silsand and Gro Hilde Severinsen: What is the role of evaluation in innovation? 20 min summary , max 5 min from each group host on their primary topic 10 min plenary dialogue facilitated by Berntsen and Steinsbekk 1. Bodenheimer T, Sinsky CJTAoFM. From triple to quadruple aim: care of the patient requires care of the provider. 2014;12(6):573-6. 2. Berntsen GKR, Strisland F, Malm-Nicolaisen K, Smaradottir B, Fensli R, Rohne M. The evidence base for an ideal care pathway for frail and multi-morbid elderly: A combined scoping review and systematic intervention review. J Med Internet Res. 2019.

Source at https://doi.org/10.1080/17482631.2019.1639461. Purpose: The number of persons living with and beyond cancer is increasing. Such persons often have complex needs that last, and change, over time. The aim of this study is to get insights of lived experience of person diagnosed with colorectal cancer and to create an understanding of cancer trajectories as a dynamic process. This study thus explores Victor Turner’s model of social drama in a cancer care context. Method: Turner suggests that crisis is a dynamic process structured by four phases: 1) breach of norm 2) crisis 3) redressive actions 4) reintegration or schism. The research team employed content analysis to explore material gathered through a series of qualitative interviews with nine Norwegian cancer patients over a period of one year. Results: To the authors’ knowledge, Turner’s model has not earlier been applied to such materials. The results show that Turner’s model of social drama is useful in achieving new and possibly important knowledge on illness trajectories from a lived experience perspective. Conclusions: The model of social drama may contribute to a deeper understanding of the processes patients are going through in long-term illness trajectories, demonstrating that illness is not a static matter.

Suicide is a major public health issue across the Arctic, especially among Indigenous Peoples. The aim of this study was to explore and describe cultural meanings of suicide among Sámi in Norway. Five open-ended focus group discussions (FGDs) were conducted with 22 Sámi (20) and non-Sámi (2) participants in South, Lule, Marka, coastal and North Sámi communities in Norway. FGDs were recorded, transcribed verbatim and analysed employing thematic analysis. Six themes were developed from the analysis: “Sámi are treated negatively by the majority society”, “Some Sámi face negative treatment from other Sámi”, “The historic losses of the Sámi have turned into a void”, “Sámi are not provided with equal mental health care”, “The strong Sámi networks have both positive and negative impacts” and “‘Birgetkultuvvra’ might be a problem”. The findings indicate that the participants understand suicide among Sámi in relation to increased problem load for Sámi (difficulties in life not encountered by non-Sámi) and inadequate problem-solving mechanisms on different levels, including lack of equal mental health care for Sámi and cultural values of managing by oneself (“ieš birget”). The findings are important when designing suicide prevention initiatives specifically targeting Sámi. © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Source at https://doi.org/10.2196/12517. Background: There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multimorbid elderly. International health organizations propose complex transformations toward digitally supported (1) Person-centered, (2) Integrated, and (3) Proactive care (Digi-PIP care). However, uncertainty regarding both the design and effects of such care transformations remain. Previous reviews have found favorable but unstable impacts of each key element, but the maturity and synergies of the combination of elements are unexplored. Objective: This study aimed to describe how the literature on whole system complex transformations directed at frail multimorbid elderly reflects (1) operationalization of intervention, (2) maturity, (3) evaluation methodology, and (4) effect on outcomes. Methods: We performed a systematic health service and electronic health literature review of care transformations targeting frail multimorbid elderly. Papers including (1) Person-centered, integrated, and proactive (PIP) care; (2) at least 1 digital support element; and (3) an effect evaluation of patient health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the descriptions to create an outline of the generic elements of a Digi-PIP care model. The authors then reviewed each intervention regarding the presence of critical elements, study design quality, and intervention effects. Results: Out of 927 potentially eligible papers, 10 papers fulfilled the inclusion criteria. All interventions idealized Person-centered care, but only one intervention made what mattered to the person visible in the care plan. Care coordinators responsible for a whole-person care plan, shared electronically in some instances, was the primary integrated care strategy. Digitally supported risk stratification and management were the main proactive strategies. No intervention included workflow optimization, monitoring of care delivery, or patient-reported outcomes. All interventions had gaps in the chain of care that threatened desired outcomes. After evaluation of study quality, 4 studies remained. They included outcome analyses on patient satisfaction, quality of life, function, disease process quality, health care utilization, mortality, and staff burnout. Only 2 of 24 analyses showed significant effects. Conclusions: Despite a strong common-sense belief that the Digi-PIP ingredients are key to sustainable care in the face of the silver tsunami, research has failed to produce evidence for this. We found that interventions reflect a reductionist paradigm, which forces care workers into standardized narrowly focused interventions for complex problems. There is a paucity of studies that meet complex needs with digitally supported flexible and adaptive teamwork. We predict that consistent results from care transformations for frail multimorbid elderly hinges on an individual care pathway, which reflects a synergetic PIP approach enabled by digital support.

Source at https://doi.org/10.1080/17482631.2018.1548240. Purpose: Person-centred care (PCC) is a well-acknowledged goal throughout the western world both within the health care services sector and for the patients themselves. To be able to create a future health care system that includes improved PCC, we need more in-depth knowledge of what matters to patients, how “what matters” might change over time, and tentative descriptions of commonalities across patients’ perspectives. The aim of this study is to contribute to this knowledge base. Methods: We conducted a qualitative interview series over one year with nine Norwegian patients who were recently diagnosed with rectal cancer tumor-node-metastasis stage I–III. Results: We found that: (1) patients have an initial focus on “biological goals” and conventional treatment; (2) pathways are unique and dynamic; (3) family and friends affected patient pathways positively with respect to meaningfulness and quality of life, but for some participants also negatively because there were heavy burdens of caretaking; (4) receiving help in the health care system depended on the patients’ navigation skills; (5) pluralism in health-seeking behaviour was important in all patient pathways. Conclusion: Long lasting illness may be a dynamic and complex journey. These results represent some features of a pathway with cancer and are important because they contribute with knowledge about what matters most seen from the cancer patients’ point of view.

Bruhopp som selvmordsmetode er et forholdsvis sjeldentfenomen, men en svaert dodelig metode. Etter en forholdsvis kortperiode pa under ett ar med flere selvmord fra Tromsobrua, bledet besluttet at brua skulle sikres. Et forhoyet rekkverk pa blemontert pa brua. RVTS Nord fikk oppdraget, i samarbeid medpolitiet i Tromso, a samle registreringer om aktivitet pa brua ogevaluere tiltaket. Siden det er to bruer naert knyttet til Tromso vardet interessant a folge med pa utviklingen pa Sandnessundbruafor a se om selvmordsaktiviteten flyttet seg til denne brua. Evalueringenav sikringstiltaket er basert pa politiets registreringerom meldinger og utrykninger til bruene i Tromso, fra 01.01.04 til31.12.14, to ar for og ni ar etter sikring. Registeringene omfatterall aktivitet med tilknytning til Tromsobrua og Sandnessundbrua,som noen har opplevd sa bekymringsfull at de har kontaktetpolitiet. Artikkelen besvarer sporsmalet: «Har sikring av Tromsobruahindra selvmord?» Selvmord ved utsprang fra hoyt sted eren lite brukt selvmordsmetode, derfor blir det sma tall nar vi kunser pa de som har hoppet. Evalueringen av sikringa av Tromsobruagir likevel noen indikasjoner pa virkningen av sikringstiltaketog dermed mer kunnskap om brusikring som selvmordsforebyggendetiltak i Tromso. En av bekymringene i forkant av sikringa,var den unge alderen til personene som dode av hopp fra brua.De fleste var under 20 ar. Vi finner ikke den samme aldersgruppablant de som har hoppet fra Sandnessundbrua etter sikring avTromsobrua. Vare data viser at det ikke har vaert en okning avdodsfall ved hopp fra Sandnessundbrua etter sikring av Tromsobrua.Pa Tromsobrua har det ikke vaert hopp med doden til folgeetter sikring. Til tross for sma tall som betyr at vi ma vaere forsiktigmed a trekke bastante konklusjoner, kan vi si at sikringen har hatten forebyggende effekt. Bade generelt og i forhold til den ungealdersgruppen som dode ved hopp fra Tromsobrua for sikring.

Background: The current logic of the care system divides the person’s health issues into a set of problems to be solved separately in parallel by respective specialists. However, such specialization predisposes the system to behave as if patients are anonymous representatives of a biological condition. This systematic depersonalization is experienced as a deeply offensive, as well as ineffective. The only person who can legitimately make overarching goals which allow all professionals to work towards a common goal across organization and specialization is the person him/herself. However, the development and recording of personal goals have little support in current care-organization and e-health systems. There is little attention on how to systematically identify the patients’ individual needs, values, preferences, and care goals, and how to apply them to treatment decisions and care evaluation. Aims and objectives: We first discuss what a systematic identification of patient goals might look like. We then discuss barriers and enablers in relation to the integration of personal goals of patients with LTC into 1) their care plans and 2) possible technologies to support the goal achievement. We apply a service design thinking approach, using service design methods including healthcare journey modelling and participatory scenario design, which can facilitate the discussion and help the participants to vocalize/articulate their thoughts and beliefs. Format: We first present an example of a successful application of goal planning among community living older adults in the Netherlands (poster ID 264, 8-10 minutes). We then have a series of short presentations about a typology of personal goals, patient empowerment, service design thinking, and the procedure of the group work (10-12 minutes). During the group work (total 40 minutes), we show a patient journey (clinical pathway) of a citizen with COPD and encourage the participants to discuss 1) barriers and enablers of integrating personal goals into this journey 2) possible technology support for the goal achievement (30 minutes). After the group work, the participants gather again and report the summary of the discussion (10 minutes). Target audience: Healthcare professionals, health service managers, administrators, policymakers, and researchers. Learnings/Take away: We expect that the participants gain new insights into the systematic identification of personal goals of people with LTC, as well as the existing barriers and enablers for integrating personal goals in their care plan. Participants will also have innovative ideas about how the goal setting can be facilitated and supported by technology assistance. The obtained ideas can be shared and used for the participants’ own projects and the participants can also take the service design thinking approach demonstrated in the workshop home to involve their local stakeholders in the further patient-centred design of care plans in digital solutions. For example, the ideas can be further discussed with individuals/citizens with LTC to co-create mutual value of digitalized individualized care plans for both caregivers and citizens with LTC.

Anita Salamonsen,1 Mona A Kiil,2 Agnete Egilsdatter Kristoffersen,1 Trine Stub,1 Gro R Berntsen1,3 1National Research Center in Complementary and Alternative Medicine, Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway; 2Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway; 3Norwegian Center for eHealth Research, University Hospital of Northern Norway, Tromsø, Norway Background: The concept of “patient pathways” in cancer care is most commonly understood as clinical pathways, operationalized as standardized packages of health care based on guidelines for the condition in question. In this understanding, patient pathways do not address multimorbidity or patient experiences and preferences. This study explored patient pathways understood as the individual and cultural life course, which includes both life and health events. The overall aim was to contribute to supportive and targeted cancer care. Materials and methods: Nine Norwegian patients recently diagnosed with rectal cancer Tumor-Node-Metastasis stage I–III participated in qualitative interviews, five times over 1 year. Five patients later participated in a workshop where they made illustrations of and discussed patient pathways. Results: Patient pathways including both health and life events were illustrated and described as complex and circular. Stress, anxiety, and depression caused by life events had significant disruptive effects and influenced patient-defined health care needs. The participants experienced the Norwegian public health service as focused on hospital-based standardized cancer care. They expressed unmet health care needs in terms of emotional and practical support in their everyday life with cancer, and some turned to complementary and alternative medicine. Conclusion: This study suggests that acknowledging life course disruption before cancer diagnosis may have significant relevance for understanding complex patient pathways and individual health care needs. Approaching patient pathways as individual and socially constructed may contribute important knowledge to support targeted cancer care. Keywords: biographical disruption, colorectal cancer, life course disruption, Norway, patient-centeredness, patient pathways, person-centered care, supportive cancer care, unmet health care needs, complementary and alternative medicine

Introduction: In response to increase of patients with complex conditions, policies prescribe measures for improving continuity of care. This study investigates policies introducing coordinator roles in Norwegian hospitals that have proven challenging to implement. Methods: This qualitative study of policy documents employed a discourse analysis inspired by Carol Bacchi’s ‘What‘s the problem represented to be?’. We analysed six legal documents (2011–2016) and selected parts of four whitepapers presenting the statutory patient care coordinator and contact physician roles in hospitals. Results: The ‘problem’ represented in the policies is lack of coherent pathways and lack of stable responsible professionals. Extended personal responsibility for clinical personnel as coordinators is the prescribed solution. Their duties are described in terms of ideals for coherent pathways across conditions and contexts. System measures to support and orchestrate the individual patient’s pathway (e.g. resources, infrastructure) are scarcely addressed. Conclusions and Discussion: We suggest that the policies’ construction of the ‘problem’ as a responsibility issue, result in that neither diversity of patients’ coordination needs, nor heterogeneity of hospital contexts regarding necessary system support for coordinators, is set on the agenda. Adoption of rhetoric from diagnosis-specific standardized pathways obscures unique challenges in creating coherent pathways for patients with complex needs. © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.

Background: There is worldwide recognition that the future provision of health care requires a reorganization of provision of care, with increased empowerment and engagement of patients, along with skilled health professionals delivering services that are coordinated across sectors and organizations that provide health care. Technology may be a way to enable the creation of a coherent, cocreative, person-centered method to provide health care for individuals with one or more long-term conditions (LTCs). It remains to be determined how a new care model can be introduced that supports the intentions of the World Health Organization (WHO) to have integrated people-centered care. Objective: To design, pilot, and test feasibility of a model of health care for people with LTCs based on a cocreative, iterative, and stepwise process in a way that recognizes the need for person-centered care, and embraces the use of digital technology. Methods: The overall research method was inspired by action research and used an agile, iterative approach. In 2012, a living lab was established in a Danish municipality which allowed for the freedom of redesigning health care processes. As the first step, a wide group of stakeholders was gathered to create a layout for the reorganization of services and development of technology, based on established principles for innovative management of people with chronic conditions. The next three steps were (1) a proof of concept in 2012, (2) a pilot study, and (3) a feasibility study from 2013 to 2015, in which a total of 93 chronic obstructive pulmonary disease (COPD) patients were enrolled. Citizens were provided a tablet-based solution for remote follow-up and communication purposes, and access to a 24/7 response and coordination center that coordinated both virtual and face-to-face support for COPD management. In step five the initial model was extended with elements that support continuity of care. Beginning in the autumn of 2013, 1102 frail elderly individuals were included and offered two additional services: an outgoing acute medical team and a local subacute bed function. Results: Based on the findings from the iterative process, and evolving technology and workflow solutions, we propose a robust and feasible model that can provide a framework for developing solutions to support an active life with one or more LTCs. The resulting Epital Care Model (ECM) consists of six stages, and serves as a template for how a digitally-enhanced health service can be provided based on patients’ medical needs. The model is designed to be a proactive, preventive, and monitoring health care system that involves individuals in the management of their own health conditions. Conclusions: The ECM is in accordance with WHO’s framework for integrated people-centered health services, and may serve as a framework for the development of new technologies and provide a template for future reorganization. [JMIR Res Protoc 2017;6(1):e6]

Background The present study protocol describes the evaluation of a comprehensive integrated care model implemented at two hospital sites at the University Hospital of North Norway (UNN). The PAtient Centred Team (PACT) model includes proactive, patient-centred interdisciplinary teams that aim to improve the continuum and quality of care of frail elderly patients and reduce health care costs. The main objectives of the evaluation are to analyse the effectiveness and cost effectiveness of using patient-centred teams as part of routine service provision for this patient group. The evaluation will analyse the effect on patient health and functional status, patient experiences and hospital utilisation, and it will conduct an economic evaluation. This paper describes the PACT model and the rationale for and design of the planned effectiveness and cost-effectiveness study. Methods/design This is a prospective, non-randomised matched control before-and-after intervention study. Patients in the intervention group will be recruited from the hospital sites that have implemented the PACT model. The controls will be recruited from two hospitals without the model. The control patients and the index patients will be matched according to sex, age and number of long-term conditions. The study aims to include 600 patients in each group, which will provide sufficient power to detect a clinical change in the primary outcome. The primary outcome is the physical dimension of the Short Form Health Survey (SF-36). Secondary outcomes are the Patient Generated Index (PGI), the Patient Activation Measure (PAM), the Patient Assessment of Chronic Illness Care (PACIC), hospitalisation and length of stay. The cost-effectiveness study takes a health provider perspective and calculates the cost per quality-adjusted life-years (QALYs) gained. The data will be collected at baseline, 6 and 12 months. The data will be analysed using techniques and models that recognise the lack of randomisation and the correlation of cost and effect data. Discussion The study results will provide knowledge about whether the integrated care model implemented at UNN improves the quality of care for the frail elderly with multiple conditions. The study will establish whether the PAC. T model improves health and functional status and is cost effective compared to the usual care for this patient group. Trial registration ClinicalTrials.gov: NCT02541474

SummaryObjectives: The aim of this study was to investigate people’s attitude towards providing symptom information electronically before a consultation. Specific areas investigated include a) attitudes and experiences with regards to acquisition of information related to symptoms, b) attitudes towards computer based communication of symptoms to the general practitioner and how they preferred to carry out such reporting, and c) attitudes towards storage, use and presentation of symptom-data in general, and particularly in a symptom based surveillance setting.Methods: Data was collected from 83 respondents by use of convenience sampling.Results: The respondents were familiar with using the Internet for health purposes, such as acquisition of information related to their symptoms prior to a consultation. The majority of respondents had a positive attitude towards providing information about their symptoms to the general practitioner’s office as soon as possible after falling ill. Over half of the respondents preferred to use e-mail or a web-interface to perform this task. Eighty four percent were willing to have their symptom data stored in their EPR and 76 percent agreed that the general practitioner might access the symptoms together with the prevalence of matching diseases in order to assist the diagnostic process during the next consultation.Conclusions: The results of this study support the applicability of electronically mediated pre-consultation systems both for improving primary care consultation and for use in symptom based surveillance, including real-time surveillance.

We assessed the association between the rate of forearm bone loss and non-vertebral fracture. Bone loss at the distal forearm predicted fractures, independently of baseline BMD, but not independently of follow-up BMD in women. The BMD level where an individual ends up is the significant predictor of fracture risk. Bone loss may predict fracture risk independently of baseline BMD. The influence of follow-up BMD on this prediction is unknown. The aim of this study was to assess the association between bone loss and fracture risk in both sexes in a prospective population-based study. We included 1,208 postmenopausal women (50 to 74 years), and 1,336 men (55 to 74 years) from the Tromso Study, who had repeated distal and ultra-distal forearm BMD measurements. Non-vertebral fractures were registered from 2001 to 2005. A total of 100 women and 46 men sustained fractures during the follow-up time. Independent of baseline BMD, the RR associated with distal site bone loss of 1 SD %/year was 1.23 (1.01-1.50) for low-trauma fractures (excluding hand, foot, skull & high-trauma) and 1.32 (1.07-1.62) for osteoporotic fractures (hip, wrist and shoulder). However, bone loss did not predict fracture after adjusting for follow-up BMD. The BMD level where an individual ends up became the significant predictor of fracture risk and not the rate of bone loss. Follow-up BMD at ultra-distal site was associated with low-trauma fractures in both sexes. While ultra-distal site BMD changes were not associated with fracture risk in both sexes. Bone loss at the distal forearm predicted non-vertebral fractures, independently of baseline BMD, but not independently of follow-up BMD, in women. The BMD level where an individual ends up is the significant predictor of fracture risk and not the rate of bone loss.

This study describes bone mineral density (BMD) and the prevalence of osteoporosis in women and men between 30-89 years in an unselected population. BMD was measured in g/cm(2) at total hip and femoral neck by dual-energy-X-ray absorptiometry in 3,094 women and 2,132 men in the 2001 Tromsø Study. BMD levels were significantly explained by age and declined progressively in both sexes from middle into old age, with highest decline in women. With osteoporosis defined as a T-score of two and a half standard deviation below the young adult mean BMD, the prevalence at the total hip in subjects above 70 years was 6.9% in men and 15.3% in women, respectively, using the Lunar reference material for T-score calculations. The prevalence increased significantly to 7.3% in men and 19.5% in women, when T-scores were calculated on basis of the young adult mean BMD (age group 30-39 years) in the study population. At the femoral neck, prevalence of osteoporosis increased from 13.5 to 18.5% in men, and from 20.4 to 35.2% in women above 70 years, respectively, depending on how T-scores were calculated. The study highlights the challenges with fixed diagnostic levels when measuring normally distributed physiologic parameters. Although BMD only partly explains fracture risk, future studies should evaluate which calculations give optimal fracture prediction.

The purpose of this study was to assess the agreement of in vivo hip scans on 3 densitometers (1 GE Lunar DPX-IQ and 2 GE Lunar Prodigy scanners) and to evaluate whether the European Spine Phantom (ESP) was able to reproduce the in vivo variability. Sixteen subjects had 3 repeated scans (with repositioning) on each densitometer, and the ESP was measured on each densitometer at least 40 times. Mean differences between hip scans on the Prodigy scanners were small and insignificant, and the in vivo results were not significantly different from the in vitro results. Bland and Altman plots showed no systematic differences between the Prodigy scanners over the range of bone mineral density (BMD). On the other hand, differences between Prodigy and DPX-IQ changed systematically over the range of BMD. The ESP did not fully reproduce the in vivo difference between Prodigy and DPX-IQ. In conclusion, the ESP is a valid substitute when assessing agreement between Prodigy scanners. However, when assessing agreement between different types of scanners, substitution of in vivo with in vitro measurements should be made with caution.

Introduction Studies show that patients with cancer who use complementary and alternative medicine (CAM) have a poorer survival prognosis than those who do not. It remains unclear whether this is due to a priori poorer prognosis that makes patients turn to CAM, or whether there is a factor associated with CAM use itself that influences the prognosis negatively. Healthcare providers should assist patients in safeguarding their treatment decision. However, the current non-communication between CAM and conventional providers leaves it up to the patients themselves to choose how to best integrate the two worlds of therapy. In this study, an interactive shared decision-making (SDM) tool will be developed to enable patients and health professionals to make safe health choices. Methods and analysis We will delineate, compare and evaluate perception and clinical experience of communication of risk situations among oncology experts, general practitioners and CAM practitioners. To accomplish this, we will develop a pilot and implement a large-scale survey among the aforementioned health professionals in Norway. Guided by the survey results, we will develop a β-version of a shared decision-making tool for healthcare providers to use in guiding patients to make safe CAM decisions. Ethics and dissemination Participants must give their informed and written consent before inclusion. They will be informed about the opportunity to drop out from the study followed by deletion of all data registered. The study needs no approval from The Regional Committee for Medical and Health Research Ethics because all participants are healthcare professionals. Results from this study will be disseminated in peer-reviewed medical journals.

Introduction: The individual care process for patients with long-term conditions is ever more a collaborative project between multiple professions, multiple organizations, guidelines, the patient and his/her significant others. This care process is here called the individual Patient Pathway (iPP). Different providers contribute to the iPP with a diverse and complementary set of skills and competencies, and can in many ways be conceptualized as a team. Vital to effective teamwork is a common understanding of goals, and how each team member’s skills and knowledge contribute to those goals. However, with many diverse legitimate contributors it is not so easy to identify what the common goal for an iPP ought to be. In settings where many care-providers work together, unrecognized variation in the implicit concepts of what goals of care ought to be, may unwittingly cause contradictory goal setting, fragmentation and disruption of care. We set out to identify literature that could help us decide what the goals of care in longterm iPPs should be. Theory/Methods: The goal of health care is to “improve and maintain health”. There is already a rich literature on health-concepts and their variations. The concept of health varies across 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117098– http://www.ijic.org/ individuals, professions, organizations and cultures. To the best of our knowledge, the variation in the nature of concepts of health and how these may affect the formulation of goals in iPPs have not previously been examined. We wished to examine whether health concepts can be grouped according their function as “goals” for the iPP, and if so, how any such typology of health concepts can help contributors to an iPP to identify common goals for care. We performed systematic searches for English language documents/articles reviewing “concepts of health” and “quality of care”. In addition, we included other health concepts, identified through the initial searches in a snowballing process. All systematic searches were done in in Medline and Web of Science®, while the additional concepts were also searched for in Google Scholar. All documents included, either described what excellent care is, or described what health is. Results: We coded the strategic sample of 64 publications into 14 different health concepts. Authors discussed excellence of care without explicit reference to their underlying concept of health / goals of care. Publications illustrating variations on health-concepts did not discuss how such variations might influence goals of care or care decisions. The disability-concept of health alone explicitly recognized and built on other concepts of health: Dis-ability/ function arises at the crossroads of biological health, personal coping skills and the social/ physical environment. Inspired by the disability concept, we developed the following typology of health-concepts: “Health is absence of biological disease”, “Health is a resource for function”, “Health is individually defined” and “Supernatural forces produce health”. The three former health concepts are complementary and all fit within a “secular” understanding of health as responsive to health care treatment. The three former concepts each point at biological-, functionaland personalgoals for care. Discussion: Health is a fluid concept. We suggest that contributors to iPPs may not necessarily share a common understanding of which goals are most important. Contributors to iPPs, including the patient, should make their goals for care explicit, and discuss how goals are aligned with oneanother, to avoid working at cross-purposes. Conclusions: Alignment of goals in IPPs will support continuity of care. Functional-, biologicaland personalgoals are complementary, and support each other. Lessons learned: The goals of care in IPPs are often implicit, which may cause disruption and confusion in IPPs. Limitations: In our literature search, we may have missed important health concepts that could have affected our health concept typology. The included publications and the authors are rooted in the western culture, so the results may not resonate with other cultural contexts. Suggestions for future research: Empirical work should verify how diversity of health concepts impact goal-setting in care. This work should continue as a broad multi-disciplinary systematic review on health concepts, with an added stakeholder Delphi process to decide on relations betweenand prioritization of concepts.

Introduction: Norway has sought to address challenges of discontinuity of care through legislation of a personal coordinator at both primary and speciality levels of care. In this paper, we highlight the “personal care coordinator” (PCC) which was introduced in specialized health care in 2012. The target group is patients with long-term needs of care from different departments and professions, independent of medical condition(s). The stated aim of the PCC legislation is to ensure continuity and coherence in the patient pathway, and the expectations towards the PCC role are wide and ambitious. However, no guidelines are offered for the design or evaluation of this role and there is uncertainty among service providers about how to move forward. We take the aim of the coordinator arrangement as a starting point in this paper. Problem statement: In what ways can research about continuity of care inform the development of the “personal care coordinator” role within specialized health care? Theory and methods: We applied a modified scoping review approach that focused on continuity of care literature on the one hand, and policy documents regarding PPC on the other. We limited our focus to literature addressing the patient perspective. Research literature from 2000-2014 were examined. Results and discussion: The literature presents multiple and often overlapping understandings of continuity of care. The policy literature gives few recommendations for the design and evaluation of this role and offer no agreed definition of continuity of care. Different understandings, dimensions and perspectives on continuity of care influence how the different coordination-of-care practices and accompanying roles for the coordinator evolve. Various models of continuity of care and possible roles of the coordinator are presented and discussed. International Journal of Integrated Care – Volume 15, 27 May– URN:NBN:NL:UI:10-1-116988 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Conclusions, key findings, lessons learned: Varying perspectives on continuity of care suggest differing approaches for improving coordinated care in specialized health care. Clarifying concepts and models focusing on coordinated care could offer guidance to leaders and policy makers. This would aid communication between differing contexts and stakeholders, and inform the design, implementation and evaluation of new solutions for improving coordinated care. However, more knowledge/understanding is needed about how the coordinating work currently is carried out in the clinical settings for patients with long-term complex needs. Limitations: Continuity of care as the chosen perspective in the literature search is limited and covers only some of the perspectives that may be useful in informing coordination-of-care practices and coordinator roles. Empirical research in progress: Studies of coordination practice in clinical settings with an institutional ethnographic approach: How is person-centred coordinating work performed today, how do the professionals understand and act towards patients’ needs for continuity, and which challenges do they experience related to the introduction of new coordinator-arrangements?

Objectives Patients with complex long-term needs experience multiple parallel care processes, which may have conflicting or competing goals, within their individual patient trajectory (iPT). The alignment of multiple goals is often implicit or non-existent, and has received little attention in the literature. Research questions: (1) What goals for care relevant for the iPT can be identified from the literature? (2) What goal typology can be proposed based on goal characteristics? (3) How can professionals negotiate a consistent set of goals for the iPT? Design Document content analysis of health service research papers, on the topic of ‘goals for care’. Setting With the increasing prevalence of multimorbidity, guidance regarding the identification and alignment of goals for care across organisations and disciplines is urgently needed. Participants 70 papers that describe ‘goals for care’, ‘health’ or ‘the good healthcare process’ relevant to a general iPT, identified in a step-wise structured search of MEDLINE, Web of Science and Google Scholar. Results We developed a goal typology with four categories. Three categories are professionally defined: (1) Functional, (2) Biological/Disease and (3) Adaptive goals. The fourth category is the patient's personally defined goals. Professional and personal goals may conflict, in which case goal prioritisation by creation of a goal hierarchy can be useful. We argue that the patient has the moral and legal right to determine the goals at the top of such a goal hierarchy. Professionals can then translate personal goals into realistic professional goals such as standardised health outcomes linked to evidence-based guidelines. Thereby, when goals are aligned with one another, the iPT will be truly patient centred, while care follows professional guidelines. Conclusions Personal goals direct professional goals and define the success criteria of the iPT. However, making personal goals count requires brave and wide-sweeping attitudinal, organisational and regulatory transformation of care delivery. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

We examined a two-step case-finding strategy where the Cummings' risk score (NEJM 1995) was applied in a population-based setting together with bone mineral density (BMD) measurements in order to validate its ability to identify women with high risk of hip fracture.All Tromsø women aged between 65 and 74 were invited to the Tromsø Osteoporosis Study (TROST) together with a 5% random sample of women aged 75-84 years (n = 1410). All had forearm BMD measurements in 1994/95 and were followed for 5 years with respect to first hip fracture. A risk score was constructed matching the Cummings score as closely as possible.In all 759, 578 and 73 women had 0-2, 3-4 and 5+ risk factors, respectively. Women with 5+ risk factors had a 5-year hip fracture risk of 11% (95% confidence interval (CI) 3.7-18.2%). BMD screening applied to these women identified 74% of them as osteoporotic and 19% as osteopenic with, respectively, 5-year hip fracture risk of 13% and 7.1%.In a population different from the one the score was generated in, this simple risk score identifies a group of women with high risk of hip fractures. With no additional BMD measurements, those high-risk women could benefit from early intervention measures.

We wanted to examine whether the features of the metabolic syndrome carried an increased risk of non-vertebral fracture. This is a population-based, 6-year follow-up of 27,159 subjects from the municipality of Tromso, followed from 1994 until 2001. Age range was 25–98 years. Non-fasting serum levels of high-density lipoprotein (HDL), triglycerides and glucose, blood pressure (BP), weight and height were measured at baseline. All non-vertebral fractures were registered by computerised search in radiographic archives. A total of 1,249 non-vertebral fractures were registered. Increasing number of metabolic syndrome features was associated with significantly reduced fracture risk in both men and women, p= 0.004 and p

The aim of this study was to describe and compare bone mineral density (BMD) development in Norwegian women and men aged 25-44 years in a population-based, longitudinal study. BMD was measured twice at distal and ultradistal forearm sites by single x-ray absorptiometry in 258 women and 147 men (mean follow-up time, 6.4 (standard deviation, 0.6) years). At the distal site, a small annual gain of approximately 0.1% became a small loss beginning at age 34 years in men and age 36 years in women. At the ultradistal site, BMD change was predicted by age in women only, and bone loss started at age 38 years. A high degree of tracking of BMD measurements was observed for both sexes and both sites, r > 0.93. Depending on total BMD change, participants were grouped into "losers", "nonlosers", and "gainers", and more than 6% lost more than the smallest detectable amount of BMD: > or =3.46% at the distal site and > or =5.14% at the ultradistal site. In both sexes, bone mineral content (grams) decreased, whereas area (centimeters squared) increased significantly in "losers" compared with "gainers". This finding might represent physiologic compensation preserving bone strength. No cohort effects were observed when 1994 and 2001 measures from similar age groups were compared.

Determination of change in bone mineral density (BMD) requires high-precision densitometry techniques. The purpose of the study is to investigate to what degree different densitometer phantoms reflect observed changes in human BMD and to investigate to what degree fluctuations in densitometers' measurement level influence bone loss estimates. Densitometer influence was assessed using the aluminum forearm phantom (AFP) provided by the manufacturer, the European forearm phantom (EFP) of semi-anthropomorphic calcium-hydroxyapatite, and repeated population measurements on different densitometer combinations. The mean follow-up time was 6.4 years (SD 0.6). Measured population bone loss varied from 4.6%/year to 3.2%/year, depending on densitometer combinations. These variations could not be explained by differences in sex, age, height, weight and baseline BMD. They were predicted by EFP measurements, but not AFP measurements. The EFP measurements indicate that X-ray tube replacement changed the densitometers' measurement level in one of three instances, whereas "wear and tear" did not. We used the EFP data for adjustment of the densitometers' measurement levels. After adjustment, the overall crude bone loss was reduced from 4.14% to 3.92%. Mean annual loss was reduced from 0.64% or 0.61%. We conclude that densitometer performance might influence the accuracy of bone loss estimates. Changes in performance are not detected by aluminum phantoms. Quality control of BMD measurements in longitudinal studies should be performed with anthropomorphic calcium-hydroxyapatite phantoms in order to detect possible differences between the participating densitometers' measurement levels.

Objective To construct reference ranges for serial measurements of umbilical artery (UA) blood flow velocity and pulsatility index (PI) at standardized insonation sites during the second half of pregnancy. Methods This was a prospective longitudinal study of the umbilical circulation. UA blood flow velocities were measured at the intra-abdominal portion, fetal end and placental end at 4-weekly intervals at 19–42 weeks of gestation in 130 low-risk singleton pregnancies. A total of 513 observations were used to construct the reference ranges using regression statistics and multilevel modeling. Results UA blood velocities and PI were higher at the intra-abdominal portion and fetal end than at the placental end. The gestational age-related increase of end-diastolic velocity was greater than the corresponding increase of the peak systolic velocity at all locations. The mean differences (delta values) of UA blood velocities between the fetal and placental ends increased and that of PI decreased with advancing gestational age. Conclusion UA Doppler parameters vary significantly at different locations. We have established new reference ranges for the UA velocities and PI at standardized locations based on longitudinal observations, which should be useful for the surveillance of fetuses with repeated observations. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

We wanted to estimate the independent fracture risk associated with chronic diseases for men and women separately, adjusting for other known risk factors. This is a population-based study of all those who attended the fourth survey (1994-1995) in the Tromso Study (n=27,159) who were followed until 31 December 2000 with respect to non-vertebral fractures. At baseline the age range was 25-98 years. Chronic disease cases were defined by self-report in questionnaires. All non-vertebral fractures were registered by computerized search in radiographic archives in the sole provider of radiographic service in the area. A total of 446 and 803 non-vertebral fractures were registered among men and women, respectively. Self-reported diabetes mellitus, stroke, asthma, hypo- and hyperthyroidism and psychiatric disorders were associated with increased fracture risk. Multivariate analyses showed an independent risk of fractures associated with self-reported diabetes mellitus, hypothyroidism and psychiatric disorders among men. Among women the independent risk was associated with self-reported asthma, hypo- and hyperthyroidism and psychiatric disorders. Self-reported heart disease had a protective effect on wrist fracture, especially in women. Increased burden of chronic diseases increase the risk of all non-vertebral (P

Objectives To construct reference ranges for serial measurements of the umbilical artery (UA) absolute blood flow velocities in the second half of pregnancy and to test the hypothesis that significant associations exist between UA velocities and placental volume blood flow assessed from umbilical vein blood flow velocities and diameter. Methods This was a prospective longitudinal study of the umbilical circulation. UA absolute velocities and umbilical vein blood flow were measured at 4-weekly intervals between 19 and 42 weeks' gestation in 130 low-risk singleton pregnancies. A total of 511 observations were used to construct the reference ranges and assess the association between UA absolute velocities and placental volume flow using multilevel modeling. Results Both UA absolute velocities and placental volume blood flow showed a steady increase throughout the second half of pregnancy. However, the gestational age-related increase in the UA end-diastolic velocity (EDV) was greater than the corresponding increase in the peak systolic velocity (PSV). The time-averaged intensity-weighted mean velocity (TAWMV)/time-averaged maximum velocity (TAMXV) was 0.6 indicating probably not a completely parabolic velocity profile. There was a significant positive association (P < 0.00001) between UA absolute velocities and placental volume blood flow, but this association was modified by the gestational age. The intraobserver coefficients of variation for the UA PSV, EDV, TAMXV and TAWMV and placental volume blood flow were 10.17%, 16.29%, 11.46%, 18.18% and 8.61%, respectively. Conclusion We have established new reference ranges for the UA absolute velocities based on longitudinal data. They show a significant association with fetoplacental volume blood flow and may have a clinical value in the assessment of the umbilical circulation. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

The purpose of this study was to examine, prospectively, the risk of non-vertebral fractures and low bone mineral density in a population-based cohort with respect to indicators of subjective mental distress. In 1979-1980 all males born 1925-1959 and all females born 1930-1959 living in Tromsø were invited (21,441; response rate, 78%). The same individuals were invited to the subsequent studies in 1986-1987 and 1994-1995 (74% attended the first two, and 71% attended all three surveys). Non-vertebral fractures were registered by linkage to the hospital X-ray register for the period 1988-1995, and forearm bone mineral density (BMD) was available in a subsample of 4,690 who had attended three times. Questions about mental distress (depression, insomnia and coping problems) were repeated three times and analyzed as cumulated exposure. Women who reported being depressed at two time points had an adjusted odds ratio (OR) =2.5 (95% confidence interval [CI] 1.3-4.9) for sustaining a non-vertebral fracture and OR=3.1 (95% CI 1.3-7.2) for sustaining an osteoporotic fracture, compared with those without depression on any occasion. The corresponding odds ratios for those with coping problems at two time points were slightly higher, whereas sleeping problems seem only to be weakly associated with non-vertebral fractures. The pattern of associations and the magnitude of OR estimates were mainly the same in women younger than 50 years and those 50 years and older. Women using nerve medicine and reporting depression twice had an odds ratio of 4.4 (95% CI 1.1-17.7) for sustaining a non-vertebral fracture, and those using nerve medicine and reporting coping problems twice had a corresponding OR 4.7 (95% CI 1.2-18.4). Among men no significant associations were found for either fracture type. No association was found between mean BMD and number of times reporting depression, insomnia or coping problems, in women or men. Long-term mental distress is associated with risk of all non-vertebral fractures and osteoporotic fractures in middle-aged women, but not in men. Mental distress itself seems to be more important than the use of nerve medicine.

Norway has a very high incidence of osteoporotic fractures, with substantial regional differences in fracture incidence. The present study evaluated whether there are differences in bone mineral density (BMD) between regions in Norway with differences in fracture incidence. The authors used data collected in four large, population-based, multipurpose studies performed in four regions of Norway during 1994-2001. Distal forearm BMD was measured by single energy x-ray absorptiometry in 10,667 participants aged 40-75 years. Cross-calibration was performed by using the European Forearm Phantom. Mean distal forearm BMD was lower in the urban populations of Tromso, Oslo, and Bergen compared with the rural county of Nord-Trondelag, whereas there was no difference between the rural part of Tromso and Nord-Trondelag. For women, body mass index explained some of these differences. The prevalence of low BMD (z score < or = -1) in Oslo, Bergen, and urban Tromso, compared with Nord-Trondelag, was 1.6-1.7 times higher in men and 1.5-2.0 times higher in women, whereas no significant difference was found between rural Tromso and Nord-Trondelag. In this study, higher BMD was found in rural compared with urban areas of Norway, which might help explain the differences in fracture incidence. There was no apparent north-south gradient in BMD.

In a population-based study of 2,586 men and 2,806 postmenopausal women aged 55-74 years in Tromsø, Norway, in 1994-1995, associations between the prevalence of abdominal aortic aneurysms and bone mineral density were examined. The presence of an abdominal aortic aneurysm was assessed by ultrasonography. The bone mineral density of the forearm was measured by single X-ray absorptiometry. In postmenopausal women aged 55-64 years (nine cases of aneurysm), the adjusted odds ratio for abdominal aortic aneurysm was 0.42 (95% confidence interval: 0.19, 0.95) for each standard-deviation increase in bone mineral density. In other age groups (65-69 years and 70-74 years) including a total of 50 cases, the corresponding odds ratios for abdominal aortic aneurysm were 1.17 and 0.70, respectively. In men aged 55-59 years, based on 45 cases, the odds ratio for abdominal aortic aneurysm was 0.72 (95% confidence interval: 0.50, 1.03). In other age groups (60-64, 65-69, and 70-74 years) including a total of 206 cases, the odds ratios ranged from 1.00 to 1.10. The associations among men (in any age group) and among women older than 64 years were not statistically significant. The authors' main conclusion is that abdominal aortic aneurysms and bone mineral density are not related. However, an association in younger subjects cannot be ruled out.