Services with low health benefits

The vast majority of what is done in hospitals today is necessary examinations and treatments. Nevertheless, it is estimated that as much as a fifth of what is done is not necessary, and in some cases even harmful to the patient. The use of such unnecessary examinations and treatments is not evenly distributed in the different health regions, but varies between hospitals.

To carry out these unnecessary examinations and treatments, resources are used that could have been used for something more important. Access to health personnel is already scarce, and will become more challenging in the future. It is therefore important that hospitals prioritize examinations and treatments with documented effect, in line with the prioritization criteria of benefit, resource use and severity.

The four regional health authorities have therefore given SKDE the task of leading an interregional effort to reduce examinations and treatments with low or uncertain health benefit. The reduction will be done nationally, so that it is the same for all patients, regardless of where in Norway they live.

In order to successfully reduce the use of unnecessary examinations and treatments, it is important to involve the medical professional communities in the work. The professional communities must help define which patients should receive, and which patients should not receive, examinations and treatments that are currently agreed to be performed too much.

The professional communities must also contribute to the work of arriving at an estimate of how many patients need the relevant examinations and treatments annually, so that there is a concrete goal to guide by. Finally, measures must be developed to achieve this goal. These measures must be rooted in both the professional communities and in the management of the regional health authorities.

Involvement of professional personnel is done by appointing professional groups within areas where it is assessed that there may be grounds for activity reduction. The professional groups must consist of representatives from the four health regions in addition to other representatives where necessary. The most important tasks of the professional groups will be to assess documentation, use their knowledge to assess whether the activity level should be reduced and propose a national target for what the activity should be. The professional groups will also propose measures to achieve these targets.

To ensure that the proposed measures are implemented, it is important to involve the management at the hospitals. This is ensured by the professional directors from the four regional health authorities acting as a steering group. In addition, the assistant professional directors at the regional health authorities will sit on a national operational group (abbreviated NOR). The operational group will provide suggestions for the types of assessment and treatment the professional groups should consider. In addition, the group is responsible for following up and implementing the measures proposed by the professional groups in their region.

Shoulder surgery

Foto: Shutterstock

Foto: Shutterstock

Shoulder pain is common and a Norwegian study from 2015 estimated that it can affect as much as half of the population in a year. In some cases, it is due to a diagnosis of subacromial pain syndrome, also called impingement syndrome. This is due to a tendon getting pinched under the bone in the shoulder, becoming irritated and inflamed. Another similar diagnosis is rotator cuff tear, where the rotator cuff muscles that stabilize the shoulder joint and contribute to shoulder mobility are torn or torn.

Both subacromial pain syndrome and rotator cuff tear can be treated conservatively (with exercise and physiotherapy) and surgically (through surgery). For subacromial pain syndrome, the surgery performed is called acromion resection and involves removing parts of the bone that are causing the tendon to be pinched. Several studies have shown that surgical treatment of these conditions has no benefits for patients compared to conservative treatment. However, the costs are higher with surgery. These were the conclusions of the Norwegian Institute of Public Health's method assessments of acromion resection for impingement syndrome in 2020-2021 and degenerative rotator cuff suture in 2023. Based on this, the Decision Forum decided in April 2021 that acromion resection should generally not be offered as a treatment for impingement syndrome. In February 2023, they decided that this should also apply to degenerative rotator cuff suture.

Despite the fact that there has been a decrease in these types of shoulder surgeries in recent years, the level is still not as low as desired. There are also large geographical differences in the use of these surgeries. Some measures to reduce the consumption of shoulder surgeries have already been initiated in some health regions. Health South-East and Health West have, among other things, decided not to purchase private services for shoulder surgery. There is still a need for a controlled reduction of shoulder surgery in the health regions.

Upper endoscopy in those under the age of 45

Foto: Shutterstock

Foto: Shutterstock

Upper endoscopy, also called gastroscopy, is an examination of the stomach and esophagus where a tube is passed through the mouth and down the esophagus to the stomach. This is basically a fairly safe procedure, but it can be very uncomfortable for those who undergo it. Upper endoscopy is one of the most commonly performed procedures in Norway, and given the high resource use of these examinations, it would be worth investigating whether there are any of these examinations that should be reduced. This is an examination that is particularly important for older age groups, to clarify symptoms that may, for example, be cancer or ulcers. In younger people, however, there are fewer cases of such diseases. This project will therefore only include those under 45 years of age. In 2022, approximately 112,000 upper endoscopies were performed in Norway, and 27 percent of these were on patients under 45 years of age.

Sørlandet Hospital is already working on a project to reduce the number of upper endoscopies in this age group. The project was started in March 2023, and as of now they have achieved a 22 percent reduction in Kristiansand, a 14 percent reduction in Arendal and a 12 percent reduction in Flekkefjord. This project could be a starting point for a possible reduction of upper endoscopies in the rest of the country as well, but may need local adjustments.

Coronary angiography in patients with chronic heart disease

Foto: Shutterstock

Foto: Shutterstock

Invasive coronary angiography is a form of X-ray examination of the coronary arteries of the heart in patients with chest pain where it is suspected that narrowed blood vessels may be the cause. This is done by inserting a catheter into an artery in the groin or wrist and guiding it up to the coronary arteries, and then injecting contrast medium into the blood vessels. This allows the blood vessels around the heart to be visualized, and it can be determined whether there are narrow areas that need immediate treatment with unblocking. However, this is an examination that carries a certain risk for the patients. In 2022, approximately 30,000 invasive coronary procedures were performed in Norway, but this includes both invasive coronary angiography and unblocking. In connection with these approximately 30,000 procedures, 267 serious complications were registered. 287 deaths were also registered in the hospital after the procedure, but it is difficult to say whether these were due to the patients' serious illness or the procedure itself.

Invasive coronary angiography is still a necessary procedure for the vast majority of patients who undergo it. But it is now also possible to use CT coronary angiography instead, which is a non-invasive X-ray examination that will be safer for patients. In addition, it is a simpler and faster procedure than invasive coronary angiography. This will be especially relevant for those with stable chronic heart disease and not those who come in with acute symptoms. Thirty-seven percent of all invasive coronary angiography in 2022 was performed on patients with chronic heart disease. Both the Norwegian Society of Cardiology and the European Society of Cardiology recommend using such simpler non-invasive examinations on patients with chronic heart disease.

SKDE has the secretariat function in both NOR and the professional groups, and is responsible for ensuring effective communication between these bodies and ensuring progress in the work. This function involves, among other things, coordination and planning of meetings, investigative work and assistance with analyses.

There are three employees in SKDE working on the assignment. Marit Herder as medical advisor, Elisabeth Pedersen as analyst and Line Strømhaug Grongstad as senior advisor.