MUNROS is funded by the European Commission FP7 programme MUNROS is funded by the European Commission FP7 programme, HEALTH-F EC. Project co-ordinators Prof Bob Elliott, and Prof Christine Bond, New Professional Roles: Processes, Productivity and Health Outcomes Jan Erik Askildsen Kamrul Islam University of Bergen, Norway

MUNROS is funded by the European Commission FP7 programme Overall objective assess the impact of the new professional roles – new roles mean undertaking roles that have traditionally been carried out by another profession as a formal part of his/her job – AMI, beast cancer, diabetes II study how the new roles have changed – health outcomes – processes outcomes – patient experiences – health care use

MUNROS is funded by the European Commission FP7 programme Formal representation Identify impact on clinical practice and outcomes – Outcome = f(personnel, share ‘new’, other) = f(L, L 2 /(L 1 +L 2 ), K) or 0 idh1c = f(L 1dh1c, K) 0 idh2c = f(L 1dh1c, L 2dh1c, K) where L is labour, and L 1 and L 2 are ‘traditional’ and ‘new’ health care professionals respectively

MUNROS is funded by the European Commission FP7 programme Outcome indicators Indicators suggested by EU ECHIM project and/or OECD HCQI project Outcomes must be hypothesized to be sensitive to changes in the types of professions involved in the provision of care, and in particular whether it is a new profession or new role

MUNROS is funded by the European Commission FP7 programme Data sources Questionnaires – distributed to patients and professionals in 9 countries Register (administrative) data Patient records

MUNROS is funded by the European Commission FP7 programme Possible indicators  Health outcomes (HO)  Mortality within 30 days  Self assessed health  Morbidity index hour?  Process measures (PM)  Unplanned readmission within 30 days after discharge from hospital  Patient experiences (PS)  Patient satisfaction  Waiting times  Health care use (HC)  Length of stay (LOS)  Number of outpatient visits  Number of GP visits

MUNROS is funded by the European Commission FP7 programme Empirical strategy Outcomes hypothesized to depend on – patients’ individual characteristics age, sex, comorbidities, severity of the disease – hospital characteristics new professionals combination of the services provided by health care professionals hospital type, size – hospital care use where patient has been treated e.g. LOS → Nested structure: - Individual and hospital level sources of variation

MUNROS is funded by the European Commission FP7 programme New professional roles Variation over hospitals and diagnoses when it comes to share of specialists – Nurses and physicians Will construct a measure for new professional roles based on questionnaires to health care professionals – Diagnoses and hospital specific – Simple measure: Share of APN, share of specialist nurse; in team

MUNROS is funded by the European Commission FP7 programme Formalization

MUNROS is funded by the European Commission FP7 programme Diagnoses and Inclusion Criteria AMI/Heart attack  Male or female  Age 21 years or older  Having a diagnosis of ICD-9: 410 or ICD-10: I21 or I22. Breast Cancer  Female  Age 21 years or older  Having a diagnosis of ICD-9: or ICD-10: C50 Empirical analyses ( An Example based on Norwegian data)

MUNROS is funded by the European Commission FP7 programme Data and Variables Data come from Norwegian Patient Register (NPR) for the years Dependent Variables: Dead within 30 days Unplanned readmission within 28 days Hospital length of Stay (LOS) – Independent Variables: Demographic: Age, gender Disease Severity: DRG weight Whether patient changed their residence from home to institution: home_inst

MUNROS is funded by the European Commission FP7 programme Descriptive Statistics AMI/Heart AttackBreast Cancer VariableNMeanStd. Dev.ObsMeanStd. Dev. dead_ readm_ LOS Age Male drg_weight home_inst Year

MUNROS is funded by the European Commission FP7 programme

MUNROS is funded by the European Commission FP7 programme

MUNROS is funded by the European Commission FP7 programme

MUNROS is funded by the European Commission FP7 programme

MUNROS is funded by the European Commission FP7 programme

MUNROS is funded by the European Commission FP7 programme

MUNROS is funded by the European Commission FP7 programme AMI/Heart Attack: Dead within 30 days Multilevel Logistic Regression Results Model 1Model 2 dead_30 Odds RatioStd. Err.zP>zdead_30 Odds RatioStd. Err.zP>z age male drg_weight home_inst LOS year _cons _cons Model 1Model 2 Residual intra-class correlation Level ICC Std. Err.Level ICC Std. Err. Hospital Hospital

MUNROS is funded by the European Commission FP7 programme AMI/Heart Attack: Unplanned Readmission within 28 days Multilevel Logistic Regression Results Model 1Model 2 readm_28 Odds RatioStd. Err.zP>zreadm_28Odds RatioStd. Err.zP>z age male drg_weight home_inst LOS year _cons _cons Model 1Model 2 Residual intra-class correlation LevelICCStd. Err.LevelICCStd. Err. Hospital Hospital

MUNROS is funded by the European Commission FP7 programme AMI/Heart Attack: Length of Hospital Stay (LOS) Multilevel Linear Regression Results Model 1Model 2 LOSCoef.Std. Err.zP>zLOSCoef.Std. Err.zP>z age male drg_weight home_inst year _cons _cons Model 1Model 2 Residual intra-class correlation Level ICC Std. Err.Level ICC Std. Err. Hospital Hospital

MUNROS is funded by the European Commission FP7 programme Breast Cancer: Dead within 30 days Multilevel Linear Regression Results Model 1Model 2 dead_30Coef.Std. Err.zP>zdead_30Coef.Std. Err.zP>z age drg_weight home_inst LOS year _cons _cons Model 1Model 2 Residual intra-class correlation LevelICCStd. Err.LevelICCStd. Err. Hospital Hospital

MUNROS is funded by the European Commission FP7 programme Breast Cancer: Unplanned Readmission within 28 days Multilevel Linear Regression Results Model 1Model 2 readm_28Coef.Std. Err.zP>zreadm_28Coef.Std. Err.zP>z age drg_weight home_inst LOS year _cons _cons Model 1Model 2 Residual intra-class correlation LevelICCStd. Err.LevelICCStd. Err. Hospital Hospital

MUNROS is funded by the European Commission FP7 programme Breast Cancer: Length of Hospital Stay (LOS) Multilevel Regression Results MODEL 1Model 2 LOSCoef.Std. Err.zP>zLOSCoef.Std. Err.zP>z age drg_weight home_inst year _cons _cons Model 1Model 2 Residual intra-class correlation Level ICC Std. Err.Level ICC Std. Err. Hospital Hospital

MUNROS is funded by the European Commission FP7 programme Conclusion Variations over hospitals in use of health care personnel Multi-level analyses indicate some possibility for this variation to result in different health outcomes – Mortality rates, unplanned readmission, LOS Questionnaires will provide more information on outcomes and health care personnel mix