Martin Strandberg-Larsen

Publications of Martin Strandberg-Larsen

• Measuring integrated care.

  Authors: Martin Strandberg-Larsen

  Danish medical bulletin. 02/2011; 58(2):B4245.

  The positive outcomes of coordination of healthcare services are to an increasing extent becoming clear. However the complexity of the field is an inhibiting factor for vigorously designed trialThe positive outcomes of coordination of healthcare services are to an increasing extent becoming clear. However the complexity of the field is an inhibiting factor for vigorously designed trial studies. Conceptual clarity and a consistent theoretical frame-work are thus needed. While researchers respond to these needs, patients and providers face the multiple challenges of today's healthcare environment. Decision makers, planners and managers need evidence based policy options and information on the scope of the integrated care challenges they are facing. The US managed care organization Kaiser Permanente has been put forward as an example for European healthcare systems to follow, although the evidence base is far from conclusive. The thesis has five objectives: 1) To contribute to the understanding of the concept of integration in healthcare systems and to identify measurement methods to capture the multi-dimensional aspects of integrated healthcare delivery. 2) To assess the level of integration of the Danish healthcare system. 3) To assess the use of joint health plans as a tool for coordination between the regional and local level in the Danish healthcare system. 4) To compare the inputs and performance of the Danish healthcare system and the managed care organization Kaiser Permanente, California, US. 5) To compare primary care clinicians' perception of clinical integration in two healthcare systems: Kaiser Permanente, Northern California and the Danish healthcare system. Further to examine the associations between specific organizational factors and clinical integration within each system. The literature was systematically searched to identify methods for measurement of integrated healthcare delivery. A national cross-sectional survey was conducted among major professional stake-holders at five different levels of the Danish healthcare system. The survey data were used to allow for analysis of the level of integration achieved. Data from the survey were additionally used to investigate the use of joint health planning as a tool for coordination of regional-local healthcare delivery. Analysis of secondary data from the Danish healthcare system and Kaiser Permanente, California were used to compare population characteristics, professional staff, delivery structure, utilisation, quality measures and direct costs. A cross-sectional survey among primary care clinicians in Denmark and in Kaiser Permanente, Northern California was completed to allow for comparison of clinical integration in the two systems and system specific associated factors. In this thesis a conceptual framework and a model for assessment of the conditions for integrations as an intermediate healthcare system outcome are presented. Furthermore, the results show that integrated healthcare delivery can be measured: 24 methods are available and some are highly developed. However, the field is still in its early phase and guidelines for how to proceed are devised. It was confirmed on a national level that integration of care is a widespread challenge, and that only half or less than half of patients in need of integrated services receive such care. Options for decision makers and managers are discussed. From a theoretical perspective joint health plans as applied in Denmark do not match the degree of complexity in the healthcare system. It was therefore in agreement with the theoretical findings when major stakeholders agreed that the joint health plans had not been effective as a tool for coordination. Joint health planning processes should actively engage all stakeholders and a high degree of recurrent feedback are warranted. When comparing Kaiser Permanente, California with the Danish healthcare system, our study suggest that Kaiser Permanente has a population with more documented disease and higher operating costs, and performs better than the Danish healthcare system on the observed quality measures. Substantial differences were found in the perception of clinical integration in the two settings. More primary care clinicians in the Northern California region of Kaiser Permanente reported being part of a clinical integrated environment than did Danish general practitioners. By measuring the level of clinical integration in Kaiser Permanente using the Danish healthcare system as a point of reference our findings support the literature that points to the importance of integrated healthcare delivery as a driver for the performance results of Kaiser Permanente. However caution must be advised before making concrete conclusions due to the complexity of the matter and until more studies have been conducted. With this thesis an initial step has been taken into a new research field. Ongoing research will make it possible to deliver the evidence needed by decision makers, planners and managers - ultimately to benefit the patients.

• Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system.

  Authors: Martin Strandberg-Larsen, Michaela L Schiøtz, Jeremy D Silver, Anne Frølich, John S Andersen, Ilana Graetz, Mary Reed, Jim Bellows, Allan Krasnik, Thomas Rundall, John Hsu

  BMC health services research. 04/2010; 10:91.

  Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective wasIntegration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

• Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system

  Authors: Martin Strandberg-Larsen, Michaela Schiøtz, Jeremy Silver, Anne Frølich, John Andersen, Ilana Graetz, Mary Reed, Jim Bellows, Allan Krasnik, Thomas Rundall, John Hsu

  BMC Health Services Research. 01/2010;

  Abstract Background Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration inAbstract Background Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Methods Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. Results More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. Conclusions More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

• Measurement of integrated healthcare delivery: a systematic review of methods and future research directions.

  Authors: Martin Strandberg-Larsen, Allan Krasnik

  International journal of integrated care. 02/2009; 9:e01.

  BACKGROUND: Integrated healthcare delivery is a policy goal of healthcare systems. There is no consensus on how to measure the concept, which makes it difficult to monitor progress. PURPOSE: ToBACKGROUND: Integrated healthcare delivery is a policy goal of healthcare systems. There is no consensus on how to measure the concept, which makes it difficult to monitor progress. PURPOSE: To identify the different types of methods used to measure integrated healthcare delivery with emphasis on structural, cultural and process aspects. METHODS: Medline/Pubmed, EMBASE, Web of Science, Cochrane Library, WHOLIS, and conventional internet search engines were systematically searched for methods to measure integrated healthcare delivery (published - April 2008). RESULTS: Twenty-four published scientific papers and documents met the inclusion criteria. In the 24 references we identified 24 different measurement methods; however, 5 methods shared theoretical framework. The methods can be categorized according to type of data source: a) questionnaire survey data, b) automated register data, or c) mixed data sources. The variety of concepts measured reflects the significant conceptual diversity within the field, and most methods lack information regarding validity and reliability. CONCLUSION: Several methods have been developed to measure integrated healthcare delivery; 24 methods are available and some are highly developed. The objective governs the method best used. Criteria for sound measures are suggested and further developments should be based on an explicit conceptual framework and focus on simplifying and validating existing methods.

• Coordination between primary and secondary healthcare in Denmark and Sweden.

  Authors: Sarah Wadmann, Martin Strandberg-Larsen, Karsten Vrangbæk

  International journal of integrated care. 02/2009; 9:e04.

  INTRODUCTION: Insights into effective policy strategies for improved coordination of care is needed. In this study we describe and compare the policy strategies chosen in Denmark and Sweden, andINTRODUCTION: Insights into effective policy strategies for improved coordination of care is needed. In this study we describe and compare the policy strategies chosen in Denmark and Sweden, and discuss them in relation to interorganisational network theory. POLICY PRACTICE: The policy initiatives to improve collaboration between primary and secondary healthcare in Denmark and Sweden include legislation and agreements aiming at clarifying areas of responsibility and defining requirements, creation of links across organisational boarders. In Denmark many initiatives have been centrally induced, while development of local solutions is more prominent in Sweden. Many Danish initiatives target the administrative level, while in Sweden initiatives are also directed at the operational level. In both countries economic incentives for collaboration are weak or lacking, and use of sanctions as a regulatory mean is limited. DISCUSSION AND CONCLUSION: Despite a variety of policy initiatives, lacking or poorly developed structures to support implementation function as barriers for coordination. The two cases illustrate that even in two relatively coherent health systems, with regional management of both the hospital and general practice sector, there are issues to resolve in regard to administrative and operational coordination. The interorganisational network literature can provide useful tools and concepts for interpreting such issues.

• A Retrospective Analysis of Health Systems in Denmark and Kaiser Permanente.

  Authors: Anne Frolich, Michaela Schiotz, Martin Strandberg-Larsen, John Hsu, Allan Krasnik, Finn Diderichsen, Jim Bellows, Jes Sogaard, Karen White

  BMC health services research. 01/2009; 8(1):252.

  ABSTRACT: BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy.ABSTRACT: BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy. METHODS: Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability. RESULTS: A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS). CONCLUSIONS: Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.

• "Making the right things easier to do". Evidence based management supports integrated care in Kaiser Permanente - Reply to editorial Guus Schrijvers December 2007.

  Authors: Michaela L Schiøtz, Martin Strandberg-Larsen

  International journal of integrated care. 02/2008; 8:e06.

• Does a public single payer system deliver integrated care? A national survey study among professional stakeholders in Denmark.

  Authors: Martin Strandberg-Larsen, Allan Krasnik

  International journal of integrated care. 02/2008; 8:e61.

  BACKGROUND: Integrated health care delivery is a goal of health care systems; to date there has been limited information on the integration of medical care in practice. PURPOSE: To examine andBACKGROUND: Integrated health care delivery is a goal of health care systems; to date there has been limited information on the integration of medical care in practice. PURPOSE: To examine and compare perceptions of clinical integration and to identify associated strategic, cultural, technical and structural factors. DESIGN AND SETTING: A NATIONAL SURVEY ADDRESSED TO: all county administrative managers (n=15); all hospital managers (n=44); and randomized selected samples of hospital department physician managers (n=200) and general practitioners (n=700) in Denmark. RESULTS: Several initiatives have been implemented in Denmark to integrate care. Nevertheless, most physicians agree that only half of all patients experience well coordinated pathways. Clinical integration is a strategic priority at the managerial levels, but this is not visible at the functional levels. Financial incentives are not used to encourage coordination. The information communication technology to facilitate clinical integration is perceived to be inadequate. CONCLUSION: The scope for improvement is high due to the structural composition of the system. Increased managerial stewardship, alignment of the financial incentives, and expanded use of information communication technology to link sub-organisations will be a way to move the system forward to meet its explicit goal of providing an integrated delivery of services.

• Are joint health plans effective for coordination of health services? An analysis based on theory and Danish pre-reform results.

  Authors: Martin Strandberg-Larsen, Mikkel Bernt Nielsen, Allan Krasnik

  International journal of integrated care. 02/2007; 7:e35.

  BACKGROUND: Since 1994 formal health plans have been used for coordination of health care services between the regional and local level in Denmark. From 2007 a substantial reform has changed theBACKGROUND: Since 1994 formal health plans have been used for coordination of health care services between the regional and local level in Denmark. From 2007 a substantial reform has changed the administrative boundaries of the system and a new tool for coordination has been introduced. PURPOSE: To assess the use of the pre-reform health plans as a tool for strengthening coordination, quality and preventive efforts between the regional and local level of health care. METHODS: A SURVEY ADDRESSED TO: all counties (n=15), all municipalities (n=271) and a randomised selected sample of general practitioners (n=700). RESULTS: The stakeholders at the administrative level agree that health plans have not been effective as a tool for coordination. The development of health plans are dominated by the regional level. At the functional level 27 percent of the general practitioners are not familiar with health plans. Among those familiar with health plans 61 percent report that health plans influence their work to only a lesser degree or not at all. CONCLUSION: Joint health planning is needed to achieve coordination of care. Efforts must be made to overcome barriers hampering efficient whole system planning. Active policies emphasising the necessity of health planning, despite involved cost, are warranted to insure delivery of care that benefits the health of the population.

• Does a public single payer system deliver integrated services? A national survey study among professional stakeholders in Denmark

  Authors: Martin Strandberg-Larsen, Allan Krasnik

• Is the Kaiser Permanente Model Superior in Terms of Clinical Integration?: A Comparative Study of Kaiser Permanente, Northern California and the Danish Healthcare System

  Authors: Martin Strandberg-Larsen, Michaela L Schiøtz, Jeremy D Silver, Anne Frølich, John S Andersen, Ilana Graetz, Jim Bellows, Allan Krasnik, Thomas Rundall, Mary Elizabeth Reed, John Hsu

  Background: Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. OurBackground: Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Methods: Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. Results: More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. Conclusions: More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.