Fokus på forskning i spesialisthelsetjenesten Habilitering

Transkript

1 Fokus på forskning i spesialisthelsetjenesten Habilitering Frode Gallefoss Forskningssjef SSHF Lungelege, dr. med., professor, UiB

2 Research expenditure in Norway compared

3 Sørlandet Hospital l 528 somatic beds, incl. patient hotel (63) l + 81 technical beds l Intensive Care Unit (ICU), post-operative og incubator l 280 psychiatric beds incl. DPS l gross man-labour years l employees l Budget billion NOK à 700 mill EURO

4 2002: Historical expectations in the region l The Sørlandet Knowledge Foundation (SKF) & the Aust-Agder foundation l Plans for University of Agder l a peripheral part of Norway that has ambitions

5 Hairy goals when the Clinical Research Department was founded in 2002 Within 10 years l 100 articles in peer reviewed journals l 10 PhD s

6 Hairy goals when the Clinical Research Department was founded in 2002 Within 10 years it became l 300 articles in peer reviewed journals l 30 PhD s

7 Established function for clinical research l Infrastructure/offices//PC s l ICT og library support l Statistics/methods seminars l «The mini-research school» l Project planning and follow-up l Engagement for supervisors l Internal controls and annual project reviews l Financial management l System development/documentation

8 The department of Clinical Research SSHF l Chief of Clinical Research l Economic management consultant l Research administrator/-supervisor l Project leader/international relations l Secretary l Biobank coordinator

9 Number of peer reviewed articles

10 Number of PhD s

11 Scientific «points»

12 Ongoing clinical research activity l External finance: l 17 PhDs & 6 PostDocs l 4 PhDs with not longer external support l Supported from clinical budget: l 4 PhDs l 15 PhDs (1 KPH)

13 Ongoing clinical research activity External finance Internal finance Total PhDs 21 (4 without current support) 19 (1 KPH) 40 PostDocs Supervisors 9(10%), 17(20%), 2(40%) 510% stilling

14 Medical specialists engaged as professor at universities l Åse Mygland, neurology UiB l Unn Ljøstad, neurology UiB l Sverre Steinsvåg, ENT UiB l Frode Gallefoss, Pulm Med UiB l Svein Gunnar Gundersen, intern. health UiA l Jon Skranes, pediatrics NTNU l Gudrun Rohde, QoL UiA l Terje Mesel, ethics UiA l Dagfinn Ulland, ethics/religion UiA

15 Future visions l Clinical research +++ l Support clinical quality improvements at SSHF l Shall SSHF become a University Hospital? l Increase the number of projects with costeffectiveness analyses l EU projects l Horizon 2020

16 Clinical research is important for the conduct of clinical skills Knowledge New science Logistics Finance Ethical guidelines Medical treatment

17 Correlations between treatment quality and clinical research Svenska Cancerfonden 2009

18 More pragmatic designs Does it work? (in daily life) Randomised controlled trials Can it work? (under ideal conditions)

19 RCT Ideal conditions Real world conditions

20 More pragmatic designs Does it work? (in daily life) Randomised controlled trials Can it work? (under ideal conditions)

21 Quality is measured indirectly à we need an indicator l Indicator l Indicare: indicate l Qualis: characteristics l Observable phenomenon that indicates the condition of a non-observable phenomenon Indicator Flee Bottom

22 International consensus on quality indicators

23 Patient security campaigns

24 Quality improvement at SSHF l The Knowledge Centre for the Health Services (part of the Norwegian Institute of Public Health) l 1-2 years delay l 30 day mortality. l Dr Foster/Global Comparator Program l 4 months delay l OOPS: Hospital data only l Statistical Process Control/PROMS l Daily dataregistration

25 2015: 4 employees pays for 1 retired 2040: <2 employees pays for 1 retired

26 United for Health (U4H) - a EU program l Collaboration with l SSHF, University of Agder, Devoteam og Kristiansand + 27 municipalities at Agder l Also supported by the Norw. Research Council l COPD: l Agder, Tromsø l Diabetes l Heart failure

27 Telemedicine Psychiatry

28 A joint telemedical system at Agder

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30 TELMA Joint telemedical system for 30 municipalities at Agder l Extension of the U4H experiences l 1.7 mill EURO from Norw. Research Council l Extends to COPD, diabetes & heart failure and comorbidity

31 PhD à eksternal finance l HSØ l NFR l Helse & Rehab/Ekstra l Lokale kompetansefond fond l Sørlandets kompetansefond & Aust-Agderfondet l Regionale forskningsfond Agder (NFR) l EU l D-stilling/fordypningsstilling l 50% forskning

32 Strong clinical research groups l Cardiology at SSA l Neurology/ tick born diseases l Centre for Cancer Treatment (SFK) l Psychiatry + Alcohol/drug abuse l Rheumatology l Gynecology l Lung diseases

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34 Strong clinical research groups l Cardiology at SSA l Neurology/ tick born diseases l Centre for Cancer Treatment (SFK) l cetuximab l Psychiatry + Alcohol/drug abuse l Rheumatology and osteoporosis l Gastroenterology l Gynecology and cancer l Lung diseases

35 Ingen spesielle forskningsmidler til habilitering?

36 Hvorfor forskning innen habilitering? l Sikre best mulig funksjons og mestringsevne, selvstendighet og deltakelse sosialt og i samfunnet for personer med medfødt eller tidlig nedsatt funksjonsevne St melding 21, 1998 l Tilby den best dokumenterte oppfølging og behandling til enhver tid l for å finne ut hva som er best, må vi forske!

37 Spesialisthelsetjenestens kjerneoppgaver er 1. Pasientbehandling 2. Pasientopplæring 3. Forskning 4. Utdanning

38 Utfordringer i habiliteringsforskning l Medisinsk diagnose (ICD 10) vs funksjonsdiagnose (ICF), paraplybetegnelse l Hvordan skille vekst, modning og naturlig forløp fra endring pga behandlingseffekt? l Kombinasjon av ulike behandlingsmåter gjør det vanskelig å isolere en av gangen l Dosering; intensitet, varighet, hyppighet, repetisjoner? l Evaluering: à mangelfulle måleinstrumenter l Etiske begrensninger ved forskning på barn l Bivirkninger tidsbruk er det verd prisen?

39 Krav til habiliteringsforskning Forskerutvalgsrapport til Shdir2006 l Fokus på kjerneinnholdet i habilitering l Høy vitenskapelig kompetanse l Tverrdisiplinær forskning l Forske på virkninger av habiliteringsprosesser l Nærhet til brukerorganisasjoner l Nærhet til praksisfeltet l Utvikle nasjonale og internasjonale nettverk

40 Hvordan forske innen habilitering? l Forskning er å stille de gode spørsmålene l Hvem får lov til å stille spørsmålene; l Fagfolkene? Foreldrene? Barna? Brukermedvirkning l Hvem bestemmer hva som er relevante spørsmål?

41 Nasjonalt forskningsnettverk innen habilitering l Nasjonalt forskningsnettverk innen habilitering l Etablert i 2010 på OUS l Økonomisk støtte fra Hdir l nasjonale årlige konferanser l Ingen har ennå oversikt over habiliteringsforskningen i HSØ eller i Norge

42 Nasjonalt forskningsnettverk innen habilitering l Målsetting l Være en møteplass for forskere innen habilitering l Være kontaktpunkt mellom norske og internasjonale forskningsmiljøer l Være pådriver for formidling av forskningsresultater l Stimulere til prosjektutvikling og prosjektsamarbeid

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44 What is the dilemma of public health information? l Those who need it the most understand it the least

45 What is of core importance in life style intervention? l Motivation

46 What it s all about.. How to elicit mo3va3on? MOTIVATION is generated from Mastery When the nega3ve aspects becomes clearer

47 Told, but not heard Heard, but not understood Understood, but not accepted Accepted, but not put into practice Put into practice, but for how long? Konrad Lorenz

48 Patient education in asthma and COPD INCLUSION CRITERIAS Asthma: n FEV1 > 80% of predicted + n 20% reversibility, variability or positive metacholine test COPD: n FEV1 < 80% of predicted with or without reversibility or variability Exclusion: n Serious medical disease:

49 Study design: 140 patients with mild to moderate asthma (n= 78) and COPD (n= 62) at our out-patient clinic after having received ordinary consultation care RANDOMISATION One-year follow-up Intervention: 2 x 2 hour group sessions individual sessions One-year follow-up Control group Followed by GP for one year Intervention group After intervention followed by GP for one year

50 INTERVENTION PROGRAM n PEF and symptom registration n Written booklet on asthma n 2 x 2 hour group sessions (5-8 patients) n 1-2 x 40 minutes individual sessions by n nurse n physiotherapist n treatment plan

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52 Consultations at GP during the one-year follow-up Mean (SD) 4 No 3 of GP consultations 2 2,6 3,4 Control Intervention 1 0,7 0,5 0 (3,6) (2,0) (5,5) (0,9) Asthma n=39/32 COPD n=27/26 p<0,001* p<0,0001* * Mann Whitney U test

53 Days off work during the one-year follow-up Mean (SD) 30 Absenteeism from work, days , (70) (32) Asthma n=24/25 (86) (7) 1 COPD n=14/13 Control Intervention p<0,05* p<0,64* * Mann Whitney U test

54 Changes in FEV1 during the one-year follow up Mean (SD) 10 p <0,05* p =0,61* Percent change in FEV1 5 3,4 2,9 5,6 Control (13) (18) (21) Intervention 0 (12) -2,7-5 Asthma COPD n=39/32 n=27/26 * T-test

55 Inhalation steroid compliance during the one-year follow-up 75 p <0.04 p =0.56 Percentage with compliance (> 75%) Control Intervention 0 Asthma n=38/30 COPD n=24/24 Compliance= (collected DDD/PDD) x 100

56 Dispensed short-acting β2- agonists during a one-year follow-up [---p= ] [---p= ] (Mann Whitney U) Percentiles 90th 75th Dispensed DDD among those who collected Median 25th 10th Control group Intervention group n= Asthma COPD

57 Four questions on Health Related Quality of Life ASTHMA Percentage at the one-year follow-up Control Intervention 25 0 A better year Symptoms <2 times a week Does not wake up No impact on daily life p=0.002* p<0.001* p=0.001* p=0.017* * Chi-square test

58 Number Needed to Educate to make one person experience ASTHMA 4 95% confidence intervals to to to 20 3,85 NNE 3 2 2,63 2,22 2, A better year Symptom free days Symptom free nights No impact on daily life

59 Health Related Quality of Life St. George s Respiratory Questionnaire Mean (SD) SGRQ Total 50 36,5 43,1 40 Score at the one-year follow-up 25 20,2 Control Intervention 0 (18) (15) Asthma n=39/32 (21) (16) COPD n=27/26 p<0,001* p<0,54* * ANOVA

60 DIRECT, INDIRECT AND TOTAL COSTS NOK, mean (SD) 12 month follow-up Control Intervention n= 39 n= 32 Education (50) Medication (3 100) (3 400) Doctor visits 700 (900) 200 (500) Hospital admissions (2 700) Travel costs 63 (89) 100 (64) Direct costs (3 800) (4 800) Production loss (33 100) (16 700) Time costs 300 (700) (600) Indirect costs (33 500) (17 300) Total costs (35 400) (20 500)

61 INCREMENTAL COST-EFFECTIVENESS RATIOES SGRQ * total scores at the one year follow-up Adjusted incremental costeffectiveness ratio per 10 unit improvement FEV1 change in % per 5% improvement Adjusted incremental costeffectiveness ratio of making one person have A better year Symptom free days Symptom free nights No impact in daily life * SGRQ = St. George s Respiratory Questionnaire

62 Conclusion patient education Asthma COPD GP visits Days off work - Steroid compl. - β 2- agonists - HRQoL - FEV1 - Total costs

63 DIRECT, INDIRECT AND TOTAL COSTS COPD, NOK, mean (SD) 12 month follow-up Control Intervention n= 27 n= 26 Education (50) Medication (4 400) (3 400) Doctor visits (1 000) 100 (200) Hospital admissions (21 000) (6 900) Travel costs 89 (200) 100 (30) Direct costs (23 300) (8 500) Production loss (20 200) 300 (1 300) Time costs 500 (1 400) 700 (700) Indirect costs (21 400) ( 1700) Total costs (38 800) (8 400)

64 Cost-benefit l l A cost-benefit ratio after patient education was calculated as follows: (Educational costs + patient time cost for educational programme)/ (total costs (Educational costs + patient time cost for educational programme)). The mean difference in total costs were NOK 9 300, while the benefit in monetary terms when adapted for the calculation of a cost-benefit ratio was ( ) = NOK The cost benefit ratio for patient education thus became 1 600: 7 700, meaning that for every NOK put into patient education, there was a saving of 4.8.

65 Conclusion COPD A one year follow-up indicates that patient education with emphasis on self-management in patients with COPD reduced the need for GP visits reduced the proportion of patients in need of GP visits improved patient satisfaction with GP reduced the need for rescue medication was cost-beneficial was cost-effective

66 Cost-effectiveness of individual smoking cessation after AMI

67 Russel, MAH: Effect of general practitioner advice against smoking BMJ, 1979, all p s < ,1 Questionnaire % 4 3 3,3 Questionnaire + advice ,6 12-month follow-up Questionnaire + advice + leaflet + warning of followup n=2000 equals 25 long-term quitters / GP / year

68 Estimated abstinence rates for various intensity levels of person-to-person contact Meta-analysis, 43 studier, Clinical Practice Guidelines, 2000, US Dep HHS Estimated 15 abstinence 10 rates % 5 0 No contact Low intensity (3-10min) Minimal counseling (<3min) Higher intensity (>10min)

69 Effekt av røykestopp etter hjerteinfarkt

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71 Det er viljen som det gjelder Viljen frigjør eller feller Henrik Ibsen

72 90 Cumulative mortality (%) Sluttet å røyke Quitted smoking Fortsatte Cont d smoking å røyke 82 % % Years after AMI/UAP 6 13 Daly, BMJ, pat.

73 70 % 60 % 50 % 40 % 57,0 % Intervention (n=100) Control (n=118) 37,3 % 30 % 20 % 10 % 0 % BMJ 2003 p=0.004 NNT: 5.1 Intention to treat analyse: 50% mot 37% (p 0.045)

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75 Comparison of the cost effectiveness of the smoking cessation program after coronary revascularisation (low risk model) with other treatment modalities in patients with coronary heart disease. Estimates are in the life time perspective. Cost in Euro per life year gained Thrombolytic therapy (1992) Aspirin in CAD (2000)* CABG/PCI high risk (1993) Statins 4S Beta blockers post-mi (1995) Cardiac rehabilitation post-mi (1995) ACEI post-mi (1995) Smoking cessation program (2000)