Terje P. Hagen

• Tjerbo, Trond; Hagen, Terje P. & Holte, Jon Helgheim (2026). When Policy Meets Reality: Municipal Leaders’ Views Amid Rising LTC Expenditure. Health Services Insights (HSI Journal). 19. doi: 10.1177/11786329251410041. Full text in Research Archive
• Godager, Geir & Hagen, Terje P. (2026). 3. Betalingssystemer. In Berg, Ole Trond; Hagen, Terje P.; Gjefsen, Hege Marie; Godager, Geir; Hart, Rannveig Kaldager; Kinge, Jonas Minet; Holte, Jon Helgheim; Aas, Eline; Kittelsen, Sverre A.C.; Moger, Tron Anders; Tjerbo, Trond; Veggeland, Frode & Øien, Henning (Ed.), Organisering og finansering av helsetjenester. Fagbokforlaget. ISSN 9788245061505. p. 39–83. doi: 10.55669/oa180903. Full text in Research Archive Show summary

  Utformingen av betalingssystemer for helsetjenesteleverandører er et betydningsfullt helsepolitisk virkemiddel. Betalingssystemer påvirker prak-tisk talt alle aspekter ved helsetjenesten ved å skape insentiver som former leverandørenes atferd, ressursallokering og til slutt pasientutfall. Selv om helsebeslutninger drives av kliniske hensyn og profesjonsetikk, har de øko-nomiske insentivene innebygd i betalingssystemene en betydelig påvirkning. Betalingssystemene etablerer den økonomiske strukturen som kliniske beslut-ninger tas innenfor.

• Haugen, Julie & Hagen, Terje P. (2026). Comparing home-based and institutional rehabilitation for community-dwelling hip fracture patients: a matched cohort study. Osteoporosis International. ISSN 0937-941X. doi: 10.1007/s00198-026-07940-8. Full text in Research Archive Show summary

  Home-based rehabilitation after hip fracture costs less than institutional care, but is care quality comparable? Using Norwegian registry data, we found that patients rehabilitated at home had substantially lower mortality and readmission rates. These findings suggest home-based rehabilitation may offer both economic and clinical advantages. Background While home-based rehabilitation following hip fracture typically costs less than institutional care, questions remain about care quality equivalence. Objective To compare care quality between home-based and institutional rehabilitation by examining 1-year mortality and 30-day readmission rates among hip fracture patients. Methods We identified 10,790 community-dwelling hip fracture patients aged 60+ from the Norwegian Patient Registry (2018–2019). Patients receiving institutional rehabilitation were matched with those receiving home-based care using propensity score matching. Logistic regression examined treatment effects on outcomes. Results After propensity score matching, home-based treatment was associated with lower mortality (OR = 0.44; 95% CI, 0.38–0.51) and lower readmission rates (OR = 0.56; 95% CI, 0.49–0.63) compared to treatment at institutions. Conclusion Community-dwelling hip fracture patients receiving institutional rehabilitation had higher mortality and readmission rates than those treated at home, suggesting superior care quality with home-based treatment.

• Kellner, Adrian; Feiring, Eli & Hagen, Terje P. (2026). Trust during COVID-19: comparing two high-trust countries with different pandemic strategies. Health Policy and Technology. ISSN 2211-8837. 15(3), p. 101170–101170. doi: 10.1016/j.hlpt.2026.101170. Full text in Research Archive Show summary

  Objectives: Sweden and Norway, two high-trust countries sharing many cultural similarities, adopted notably different strategies in the initial phase of the COVID-19 pandemic. While Sweden relied on a mitigation strategy emphasising individual responsibility, Norway swiftly imposed strict restrictions. This study aimed to examine whether levels of political and social trust differed between the two countries, whether trust changed from before to after the pandemic, and whether any changes differed between the countries in ways consistent with their divergent pandemic strategies. Methods: We analysed data from the repeated cross-sectional European Social Survey (ESS) covering rounds from 2018/19 and 2022/23 to assess levels and changes in political and social trust in Sweden and Norway. In parallel, we used data from the VaxPref survey (2022–2023), a cross-sectional survey, to examine how trust in public health authorities, newspapers, and social media related to COVID-19 infection and individual characteristics. Variation in trust was analysed using ordinary least squares regression models. Results: Political and social trust were high in both countries, though consistently higher in Norway than in Sweden both before and after the pandemic. Trust levels remained stable over time in both countries, with no significant changes between the pre-pandemic and post-pandemic periods. We found no differential trends between Sweden and Norway that could be attributed to their different pandemic strategies. COVID-19 infection was not associated with trust levels in either country. Conclusion: Despite their markedly different pandemic management strategies, both countries exhibited stable levels of political and social trust throughout the period studied. The findings suggest a sustained rally-around-the-flag effect in both high-trust societies, indicating that the choice of pandemic strategy, whether strict lockdowns or voluntary compliance, did not undermine trust in institutions or fellow citizens.

• Antonini, Marcello; Singh, Renu; Torbica, Alessia Melegaro Aleksandra; Ward, Jeremy Keith; Berardi, Chiara & Attwell, Katie [Show all 15 contributors for this article] (2026). Democracy, Trust, and Political Orientation: Disentangling Mechanisms Shaping Individuals’ Vaccine Attitudes. Journal of Health Politics Policy and Law. ISSN 0361-6878. 51(1), p. 45–82. doi: 10.1215/03616878-12166725. Full text in Research Archive Show summary

  Context: In recent decades, many countries experienced a reduction in the quality and functioning of democratic institutions and norms accompanied by rising social distrust and opposing political views. The decline in vaccine confidence might be linked to these trends. This study explores the political factors influencing individual attitudes toward vaccination across 22 upper-middleincome and high-income countries, examining the interaction between political orientation, trust in public health authorities, and levels of democracy. Methods: The authors used the VaxPref database, encompassing demographically representative data from 50,242 respondents collected between July 2022 and June 2023, to conduct an analysis on three levels: pooled sample, democracy groups, and country-specific analyses. Results: The authors found that higher democracy scores generally correlated with lower levels of vaccine skepticism. People in the political center and on the political right expressed more skepticism toward vaccines overall. However, trust in public health authorities emerged as the determinant that explains the largest variation in vaccine attitudes. Conclusions: These findings suggest a greater effectiveness of democratic systems in fostering vaccine confidence and the need to depoliticize vaccination efforts. Building and maintaining trust in scientific information and technical expertise is critical. Blunt measures like vaccination mandates may not sustain long-term confidence, particularly in democratic contexts. Effective interventions should prioritize comprehensive school-based education to promote preventive health behaviors coupled with targeted trust-enhancing communication strategies.

• Hagen, Terje P. & Feiring, Eli (2025). Health Policy Reforms for Three Decades. In Kolltveit, Kristoffer; Allern, Elin Haugsgjerd; Braut-Hegghammer, Målfrid & Rasch, Bjørn Erik (Ed.), The Oxford Handbook of Norwegian Politics. Oxford University Press. ISSN 9780198888581. p. 590–604. doi: 10.1093/oxfordhb/9780198888581.013.0031. Full text in Research Archive Show summary

  This chapter examines Norway’s semi-decentralized national health service system, with municipalities responsible for primary health care and social services and with specialist care administered by state-owned regional health authorities. The provision of services free of charge has led to a significant demand that often surpasses the supply capacity. To address this issue, rationing is implemented through various mechanisms, primarily through allocating predominantly global budgets to regional health authorities and municipalities. In addition, Norway has adopted an explicit priority-setting approach for resource allocation within the health-care sector. Together with the use of ‘top-up’ economic incentives, this approach has helped reduce the problem of long waiting times, which is prevalent in many countries with tax-based health insurance. However, critics argue that models reliant on economic incentives have overshadowed traditional principles of accountability based on trust, and we now observe a reduction of these incentives and a search for alternatives.

• Hagen, Terje P. & Anthun, Kjartan Sarheim (2025). Sykehusenes kostnadsnivå før og etter investeringer i bygningsmassen. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 145(14). doi: 10.4045/tidsskr.24.0679. Full text in Research Archive Show summary

  Bakgrunn Investeringer i sykehusbygg er i Norge delvis basert på forventninger om høyere kostnadseffektivitet i etterkant. Helseforetakene skal behandle pasientene til en lavere kostnad enn før investeringen, slik at gevinsten kan benyttes til å betjene kapitalkostnader. Formålet med vår analyse er å etterprøve om denne forventningen innfris. Materiale og metode Data om driftskostnader og DRG-poeng for alle helseforetak er hentet fra SAMDATA spesialisthelsetjenesten i perioden 1999–2023. Analysene gjennomføres som toveis variansanalyse (ANOVA), med logaritmen av sykehusenes kostnadsnivå som avhengig variabel. Perioden fra 1999 til ett år før implementeringen av investeringen benyttes som referanseperiode. Resultater Investeringer i bygningsmassen var assosiert med kostnadsøkninger på kort sikt. Kostnadsøkningene startet året før iverksettelsen av investeringene og var 4,9 % (95 % konfidensintervall (KI) 0,7 til 9,0) over kostnadsnivået i referanseperioden, året etter iverksettelsen av investeringene. Fra og med år fire etter investeringen var det gjennomsnittlige kostnadsnivået tilbake på referansenivået. Sensitivitetsanalyser indikerte at i prosjekter der hele bygningsmassen ble fornyet, var det ingen statistisk signifikante endringer i kostnadsnivået de tre første årene etter implementeringen, men fra fire år og utover ble det et signifikant redusert kostnadsnivå på -4,4 % (95 % KI -7,9 til -1,0). Fortolkning Forventningene om kostnadseffektivisering ble på gruppenivå ikke oppnådd ved investeringene i bygningsmasse som ble gjennomført i perioden 2003–23. Dette gir grunnlag for å stille spørsmål ved realismen i de regionale helseforetakenes investeringskalkyler.

• Antonini, Marcello; Genie, M. G.; Attwell, Katie; Attema, Arthur E; Ward, Jeremy K & Melegaro, Alessia [Show all 19 contributors for this article] (2025). Are we ready for the next pandemic? Public preferences and trade-offs between vaccine characteristics and societal restrictions across 21 countries. Social Science and Medicine. ISSN 0277-9536. 366. doi: 10.1016/j.socscimed.2025.117687. Full text in Research Archive Show summary

  In vaccination decisions, individuals must weigh the benefits against the risks of remaining unvaccinated and potentially facing social restrictions. Previous studies have focused on individual preferences for vaccine characteristics and societal restrictions separately. This study aims to quantify public preferences and the potential trade-offs between vaccine characteristics and societal restrictions, including lockdowns and vaccine mandates, in the context of a future pandemic. We conducted a discrete choice experiment (DCE) involving 47,114 respondents from 21 countries between July 2022 and June 2023 through an online panel. Participants were presented with choices between two hypothetical vaccination programs and an option to opt-out. A latent class logit model was used to estimate trade-offs among attributes. Despite some level of preference heterogeneity across countries and respondents’ profiles, we consistently identified three classes of respondents: vaccine refusers, vaccine-hesitant, and pro-vaccine individuals. Vaccine attributes were generally deemed more important than societal restriction attributes. We detected strong preferences for the highest levels of vaccine effectiveness and for domestically produced vaccines across most countries. Being fully vaccinated against COVID-19 was the strongest predictor of pro-vaccine class preferences. Women and younger people were more likely to be vaccine refusers compared to men and older individuals. In some countries, vaccine hesitancy and refusal were linked to lower socioeconomic status, whereas in others, individuals with higher education and higher income were more likely to exhibit hesitancy. Our findings emphasize the need for tailored vaccination programs that consider local contexts and demographics. Building trust in national regulatory authorities and international organizations.

• Aga, Ruth; Søgaard, Anne-Johanne; Holvik, Kristin; Hagen, Terje P.; Idland, Gro & Jeyananthan, Anita [Show all 10 contributors for this article] (2025). Effectiveness of a fall and fracture prevention pathway on hip fracture risk, need of permanent care and mortality: a controlled before-and-after study. Age and Ageing. ISSN 0002-0729. 54(6). doi: 10.1093/ageing/afaf161. Full text in Research Archive Show summary

  Background The high rates of hip fracture in Oslo inspired a new fall prevention pathway based on well-established fall prevention strategies, but specifically focusing on care coordination, osteoporosis treatment and targeting high-risk patients. Objective To evaluate the effectiveness of the fall prevention pathway. Methods We performed a controlled before-and-after study in the home-dwelling population aged 65+ years in Oslo, Norway. The intervention consisted of identifying older adults with a fall-related injury, offering them risk assessment and tailored interventions. Using registry data, we compared registered fallers in the two intervention boroughs with the remaining 13 boroughs as controls, with registered fall injuries as time-dependent exposure in Cox regression. Hazard ratios (HRs) for later hip fracture, long-term care and all-cause mortality were estimated, adjusting for the pre-intervention period. Results The risk of hip fracture for the Oslo population aged 65+ years declined by 23% from 2012–19. HR for hip fracture amongst registered fallers in the intervention boroughs compared to the controls was 0.95 (95% CI 0.64–1.41). The difference was significant in men only [HR 0.45 (95% CI 0.21–0.95)]. The risk of admittance to long-term care was reduced [HR 0.76 (95% CI 0.62–0.93)]. No significant difference was seen in mortality. Conclusions Overall, the risk of later hip fracture was not significantly reduced in all registered fallers in the intervention boroughs, only in men. There was a significant decline in risk of admission to nursing homes in the intervention boroughs. These results suggest that the prevention pathway might have slowed down functional decline in the older Oslo population.

• Mishra, Vinod Kumar; Gedde-Dahl, Tobias; Remberger, Mats; Solvang, Grethe; Selvaag, Kristin Mill Lien & Fosseng, Arne [Show all 10 contributors for this article] (2025). Hospital at Home Following Allogeneic Hematopoietic Stem Cell Transplantation: An Economic Analysis. Healthcare. doi: 10.3390/healthcare13141648. Full text in Research Archive Show summary

  Background: Advanced home care is becoming increasingly common for cancer patients and serves as a viable alternative to inpatient hospital care. The transition to home care is driven by both the rising costs of healthcare and evidence indicating better quality of care. This study aims to compare the costs of hospital-at-home treatment and in-hospital care for patients undergoing allo-HSCT. Methods: The cost analysis was conducted as a case–control study comparing the costs of allo-HSCT at home (HaH) to the costs of allo-HSCT for patients receiving in-hospital care (INH). The cost evaluation was conducted from the hospital’s perspective, which means that costs incurred outside the hospital setting were not included. Post-procedural costs for the first year after allo-HSCT included all readmissions and outpatient visits at Oslo University Hospital. Results: The cost for the peritransplant period could be reduced by up to 33% by treating allo-HSCT recipients at home instead of in the hospital. During the study period, 24% of the allo-HSCT recipients were treated at home, but our data from 2021 and 2022 indicate that at least a third of the patients scheduled for allo-HSCT are candidates for HaH. Conclusions: The findings demonstrate that patients in advanced home care experience significantly lower total costs compared to those receiving in-hospital treatment.

• Pallari, Chryso Th.; Achilleos, Souzana; Quattrocchi, Annalisa & Hagen, Terje P. (2025). Sustained excess all-cause mortality post COVID-19 in 21 countries: an ecological investigation. International Journal of Epidemiology. ISSN 0300-5771. doi: 10.1093/ije/dyaf075. Full text in Research Archive Show summary

  Background Despite widespread vaccination efforts, significant excess mortality continued in various countries following the COVID-19 pandemic. This study aims to estimate excess mortality during 2022 in 21 countries and regions, and to examine the relationship of governmental control measures and vaccination rates with excess mortality during 2021–2 at an ecological level. Methods Excess mortality for 2022 was estimated by analysing weekly mortality data from January 2020 to December 2022 across 21 countries and regions participating in the C-MOR consortium. This was achieved by comparing the observed age-standardized mortality rates per 100 000 population to a baseline derived from historical data (2015–19). Governmental control measures and vaccination efforts were investigated for their association with weekly excess mortality during 2021–2 in multilevel models with country as a random effect. Results All 21 countries experienced excess mortality in 2022, ranging from 8.6 (Peru) to 116.2 (Georgia) per 100 000 population, noting that rates were not directly comparable across countries. Many countries had higher excess mortality in 2022 compared with previous years. Mauritius showed a significant excess mortality for the first time in 2022. The proportion of COVID-19 deaths relative to total deaths decreased in 2022 for most countries, except Australia. Governmental control measures and vaccinations were associated with reduced excess mortality in 2021 and 2022, respectively. Conclusion The study reveals sustained excess mortality throughout 2022. Excess deaths were mainly non-COVID-19-related, likely due to displaced mortality or to broader long-term impacts of the pandemic response. Governmental control policies and vaccination efforts were associated with lower excess mortality. These findings provide critical insights into pandemic mortality dynamics and emphasize the need for continued vigilance and adaptive public health strategies.

• Hagen, Terje P. (2024). Ulikheter i tjenestetilbudet mellom norske kommuner. Tidsskrift for omsorgsforskning. ISSN 2387-5976. 10, p. 90–107. doi: 10.18261/tfo.10.2.7. Full text in Research Archive Show summary

  I Norge benyttes kommunene til å tilby pleie- og omsorgstjenester. Intensjonen er at dette skal gi koblinger mellom lokale ønsker og tildeling av tjenestene, og bred politisk deltakelse i beslutningsprosessene. Kommunesektoren i Norge benyttes også til andre oppgaver, blant annet til å nå regionalpolitiske målsettinger ved at kommuner i næringssvake områder tildeles egne overføringer. Spørsmålet vi stiller, er om statlige prioriteringer som påvirker kommunale inntekter, i neste omgang påvirker kommunenes utgifter til pleie- og omsorgstjenestene, og sannsynligheten for at den enkelte brukeren får tildelt tjenester. En paneldataanalyse som dekker perioden 1972–2022, viser at kommunenes utgifter til pleie- og omsorgstjenestene øker med kommunenes inntekter og endringer i demografi. I tillegg er det betydelige effekter av nasjonale reformer, særlig HVPU-reformen, som ble gjennomført fra 1991. En tverrsnittsanalyse på individnivå basert på data fra 2019, viser at tildelingen av langtidsplass i sykehjem for brukere som er 70 år eller eldre, er assosiert med kommunens inntektsnivå. Brukere i kommunene med de høyeste inntektene har om lag 37 prosent større sjanse for å få sykehjemsplass enn brukere i kommuner med lavest inntektsnivå. Når det gjelder det generelle nivået på tildelte tjenester målt ved utgifter per bruker, så øker også dette med kommunenes inntekter, men variasjonen i utgifter er mindre enn variasjonen i kommunale inntekter. I tillegg til distriktspolitiske overføringer er høyinntektskommunene kjennetegnet av høye skatteinntekter fra personer, kraftproduksjon eller petroleumsvirksomhet. Vi konkluderer med at det er motsetninger mellom statens målsetting om likeverdig tjenestetilbud i pleie- og omsorgstjenestene og den store inntektsvariasjonen det er mellom kommunene. Inntektsvariasjonen kommer som følge av at noen skatteinntekter ikke jevnes ut, og at noen kommuner får store regionalpolitiske overføringer.

• Haghighi, Mohammad Reza Rahmanian; Haghighi, Mohammad Reza Rahmanian; Pallari, Chryso Th; Pallari, Chrysto; Achilleos, Souzana & Quattrocchi, Annalisa [Show all 46 contributors for this article] (2024). Excess Mortality and its Determinants During the COVID-19 Pandemic in 21 Countries: An Ecological Study from the C-MOR Project, 2020 and 2021. Journal of Epidemiology and Global Health (JEGH). ISSN 2210-6006. 14(4), p. 1650–1661. doi: 10.1007/s44197-024-00320-7. Full text in Research Archive Show summary

  Introduction The COVID-19 pandemic overwhelmed health systems, resulting in a surge in excess deaths. This study clustered countries based on excess mortality to understand their response to the pandemic and the influence of various factors on excess mortality within each cluster. Materials and Methods This ecological study is part of the COVID-19 MORtality (C-MOR) Consortium. Mortality data were gathered from 21 countries and were previously used to calculate weekly all-cause excess mortality. Thirty exposure variables were considered in five categories as factors potentially associated with excess mortality: population factors, health care resources, socioeconomic factors, air pollution, and COVID-19 policy. Estimation of Latent Class Linear Mixed Model (LCMM) was used to cluster countries based on response trajectory and Generalized Linear Mixture Model (GLMM) for each cluster was run separately. Results Using LCMM, two clusters were reached. Among 21 countries, Brazil, the USA, Georgia, and Poland were assigned to a separate cluster, with the mean of excess mortality z-score in 2020 and 2021 around 4.4, compared to 1.5 for all other countries assigned to the second cluster. In both clusters the population incidence of COVID-19 had the greatest positive relationship with excess mortality while interactions between the incidence of COVID-19, fully vaccinated people, and stringency index were negatively associated with excess mortality. Moreover, governmental variables (government revenue and government effectiveness) were the most protective against excess mortality. Conclusion This study highlighted that clustering countries based on excess mortality can provide insights to gain a broader understanding of countries' responses to the pandemic and their effectiveness.

• Bjørnelv, Gudrun Maria Waaler; Aas, Eline; Aaltonen, Mari; Hagen, Terje P.; Thoresen, Lisbeth & Forma, Leena (2024). Place of living at end-of-life according to cause of death: a comparative analysis of all decedents 70 years or older in 2009-2013 in Finland and Norway. Annals of Palliative Medicine. ISSN 2224-5820. 13(3). doi: 10.21037/apm-23-269. Full text in Research Archive Show summary

  Background: Time at home at end-of-life is perceived as valuable to individuals. Increasing home care is therefore often a political goal. Yet, little is known about where individuals live towards their end-of-life. Our aim was to describe where individuals reside their last 6 months of life in Finland and Norway, and how this differed by cause of death, sex, age, marital status, and income. Methods: We used individual-leveled national registry data on all decedents aged >70 years in 2009–2013 to describe the number of days individuals spent at home, in hospital, in long-term care (LTC) and short-term care (STC) facilities. We described the place of residence for all and by causes of death: cancer, diseases of the circulatory system, disease in the respiratory system, and mental and behavioral disorders (primarily dementia). We analyzed how age, marital status (indicating informal care), and income associated with place of residence. Analyses were stratified by sex and country. Results: During the last 6 months of life, decedents in Finland (n=186,017) and Norway (n=159,756) spent similar amounts of days in hospital (8 and 11 days) and in STC facilities (15 and 13 days). Finnish decedents spent more days at home (96 vs. 84 days) and fewer days in LTC facilities (64 vs. 80 days). Living arrangement differed similarly by cause of death in the two countries, e.g., decedents from cancer and mental and behavioral disorders spent 123 [113] vs. 29 [21] days at home in Finland (Norway). In both countries, for all causes of death, lower age and marital status were associated with more days at home, for both males and females. While those with higher income spent more days at home in Norway, the opposite was found in Finland. Conclusions: Older individual’s living arrangements in the last 6 months of life were similar in Finland and Norway but differed by cause of death. Younger individuals and those with access to informal care spent more days at home, compared to their counterparts. With aging populations, more individuals will likely need LTC at their end of life. Policies should align with these needs when developing future health care services.

• Hagen, Terje P. (2024). Sykehustalen 2024 – hva skjer med sykehusfinansieringen? Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 144(3). doi: 10.4045/tidsskr.24.0051. Full text in Research Archive
• Antonini, Marcello; Genie, Mesfin; Attema, Arthur; Attwell, Katie; Balogh, Zsolt & Behmane, Daiga [Show all 24 contributors for this article] (2024). Public preferences for vaccination campaigns in the COVID-19 endemic phase: insights from the VaxPref database. Health Policy and Technology. ISSN 2211-8837. 13(1). doi: 10.1016/j.hlpt.2024.100849. Full text in Research Archive Show summary

  Objective Despite widespread perceptions that SARS-CoV-2 (COVID-19) is no longer a significant threat, the virus continues to loom, and new variants may require renewed efforts to control its spread. Understanding how individual preferences and attitudes influence vaccination behaviour and policy compliance in light of the endemic phase is crucial in preparation for this scenario. Method This paper presents descriptive data from a global stated choice survey conducted in 22 countries across 6 different continents between July 2022 and August 2023, and reports the methodological work developed to address the need for comparable data. Results This study included 50,242 respondents. Findings indicated significant heterogeneity across countries in terms of vaccination status and willingness to accept boosters. Vaccine hesitancy and refusal were driven by lower trust in public health bodies, younger age, and lower educational levels. Refusers and hesitant people reported lower willingness to take risks compared to those fully vaccinated (p<0.05). Lower mental health levels were found for the hesitant cohort (p<0.05). Conclusions Insights from this database can help public health authorities to gain a new understanding of the vaccine hesitancy phenomenon, support them in managing the transition from the pandemic to the endemic phase, and favour a new stream of research to maximise behavioural response to vaccination programs in preparation of future pandemics.

• Pallari, Chryso Th.; Achilleos, Souzana; Quattrocchi, Annalisa; Gabel, John; Critselis, Elena & Athanasiadou, Maria [Show all 46 contributors for this article] (2024). Magnitude and determinants of excess total, age-specific and sex-specific all-cause mortality in 24 countries worldwide during 2020 and 2021: results on the impact of the COVID-19 pandemic from the CMOR project. BMJ Global Health. 9(4). doi: 10.1136/bmjgh-2023-013018. Full text in Research Archive Show summary

  Introduction To examine the impact of the COVID-19 pandemic on mortality, we estimated excess all-cause mortality in 24 countries for 2020 and 2021, overall and stratified by sex and age. Methods Total, age-specific and sex-specific weekly all-cause mortality was collected for 2015–2021 and excess mortality for 2020 and 2021 was calculated by comparing weekly 2020 and 2021 age-standardised mortality rates against expected mortality, estimated based on historical data (2015–2019), accounting for seasonality, and long-term and short-term trends. Age-specific weekly excess mortality was similarly calculated using crude mortality rates. The association of country and pandemic-related variables with excess mortality was investigated using simple and multilevel regression models. Results Excess cumulative mortality for both 2020 and 2021 was found in Austria, Brazil, Belgium, Cyprus, England and Wales, Estonia, France, Georgia, Greece, Israel, Italy, Kazakhstan, Mauritius, Northern Ireland, Norway, Peru, Poland, Slovenia, Spain, Sweden, Ukraine, and the USA. Australia and Denmark experienced excess mortality only in 2021. Mauritius demonstrated a statistically significant decrease in all-cause mortality during both years. Weekly incidence of COVID-19 was significantly positively associated with excess mortality for both years, but the positive association was attenuated in 2021 as percentage of the population fully vaccinated increased. Stringency index of control measures was positively and negatively associated with excess mortality in 2020 and 2021, respectively. Conclusion This study provides evidence of substantial excess mortality in most countries investigated during the first 2 years of the pandemic and suggests that COVID-19 incidence, stringency of control measures and vaccination rates interacted in determining the magnitude of excess mortality.

• Hagen, Terje P. & Zelko, Erika (2024). Exploring End-of-Life Care for Patients with Breast Cancer, Dementia or Heart Failure: A Register-Based Study of Individual and Institutional Factors. Healthcare. 12(9). doi: 10.3390/healthcare12090943. Full text in Research Archive Show summary

  Objective: To examine variations in end-of-life care for breast cancer, heart failure, and dementia patients. Data and methods: Data from four Norwegian health registries were linked using a personal identification number. Longitudinal trends over 365 days and the type of care on the final day of life were analyzed using descriptive techniques and logistic regression analysis. Results: Patients with dementia were more commonly placed in nursing homes than patients in the two other groups, while patients with heart failure and breast cancer were more frequently hospitalized than the dementia patients. Breast cancer and heart failure patients had a higher likelihood of dying at home than dementia patients. The higher the number of general practitioners, the higher was the probability of home-based end-of-life care for cancer patients, while an increasing non-physician healthcare workers increased the likelihood of home-based care for the other patient groups. Conclusions: Diagnoses, individual characteristics, and service availability are all associated with the place of death in end-of-life care. The higher the availability of health care services, the higher also is the probability of ending the life at home.

• Hagen, Terje P.; Tjerbo, Trond & Aarflot, Morten (2024). Pasienter nyinnlagt i sykehjem – alder, tilstand og funksjonsnivå. Michael. ISSN 1893-9651. 21(1), p. 23–38. doi: 10.5617/michael.10949. Full text in Research Archive Show summary

  Sykehjemmene er en hjørnestein i kommunehelsetjenesten. De siste årene er antall sykehjemsplasser blitt redusert. Har det skjedd endringer i populasjonen av pasienter som er i langtidsopphold i sykehjemmene? Hensikten med denne artikkelen er å gi en nærmere beskrivelse av pasientpopulasjonen i kommunale helseinstitusjoner der sykehjemsplasser utgjør mer enn 95 % av plassene. Våre hovedfunn, basert på individdata fra Kommunalt pasient- og brukerregister fra perioden 2017–2021, er at det skjer en foryngelse av sykehjemsbeboerne, men at 70 % av dem fortsatt er 80 år eller eldre. I de eldre aldersgruppene som legges inn i langtidsopphold, finner vi overvekt av pasienter med hjerte- og karlidelser, nevrologiske lidelser og demens, mens psykiske og nevrologiske lidelser er de største sykdomsgruppene i de lavere aldersgruppene. Funksjonsevnen til eldre som er nyinnlagt, er noe redusert over tid. Det kan indikere at terskelen for å få langtidsplass er hevet for denne gruppen. Nyinnlagte pasienter i de lavere aldergruppene har imidlertid dårligere funksjonsevne enn de eldre. Våre resultater indikerer at inntakene til sykehjemmene reflekterer prioriteringskriteriene når vi betrakter landet samlet. Kommunenes utgifter til institusjonene ser ikke ut til å øke som følge av at andelen yngre pasienter som får langtidsplass, øker.

• Häkkinen, Unto; Hagen, Terje P. & Kittelsen, Sverre (2023). 20 years of Nordic comparative health economics research. Nordic Journal of Health Economics. ISSN 1892-9729. 6(1), p. 59–79. doi: 10.5617/njhe.10133. Full text in Research Archive Show summary

  Nordic comparative health economics research stands out internationally both by its access to excellent patient data and its long-time commitment to rigorous analyses. In this article, we present the methodological foundations and the results from two types of performance analyses – comparative analyses of health care outcomes and costs at hospital level and similar analyses at the disease level. In the concluding part, we discuss strength and weaknesses of the Nordic comparative analyses, and how we should develop Nordic comparative health economics research further.

• Demetriou, Christiana A.; Achilleos, Souzana; Quattrocchi, Annalisa; Gabel, John; Critselis, Elena & Constantinou, Constantina [Show all 37 contributors for this article] (2023). Impact of the COVID-19 pandemic on total, sex-and age-specific all-cause mortality in 20 countries worldwide during 2020: Results from the C-MOR project. International Journal of Epidemiology. ISSN 0300-5771. 52(3), p. 664–676. doi: 10.1093/ije/dyac170. Full text in Research Archive Show summary

  Abstract Background To understand the impact of the COVID-19 pandemic on mortality, this study investigates overall, sex- and age-specific excess all-cause mortality in 20 countries, during 2020. Methods Total, sex- and age-specific weekly all-cause mortality for 2015–2020 was collected from national vital statistics databases. Excess mortality for 2020 was calculated by comparing weekly 2020 observed mortality against expected mortality, estimated from historical data (2015–2019) accounting for seasonality, long- and short-term trends. Crude and age-standardized rates were analysed for total and sex-specific mortality. Results Austria, Brazil, Cyprus, England and Wales, France, Georgia, Israel, Italy, Northern Ireland, Peru, Scotland, Slovenia, Sweden, and the USA displayed substantial excess age-standardized mortality of varying duration during 2020, while Australia, Denmark, Estonia, Mauritius, Norway, and Ukraine did not. In sex-specific analyses, excess mortality was higher in males than females, except for Slovenia (higher in females) and Cyprus (similar in both sexes). Lastly, for most countries substantial excess mortality was only detectable (Austria, Cyprus, Israel, and Slovenia) or was higher (Brazil, England and Wales, France, Georgia, Italy, Northern Ireland, Sweden, Peru and the USA) in the oldest age group investigated. Peru demonstrated substantial excess mortality even in the &amp;lt;45 age group. Conclusions This study highlights that excess all-cause mortality during 2020 is context dependent, with specific countries, sex- and age-groups being most affected. As the pandemic continues, tracking excess mortality is important to accurately estimate the true toll of COVID-19, while at the same time investigating the effects of changing contexts, different variants, testing, quarantine, and vaccination strategies.

• Holte, Jon Helgheim; Hagen, Terje P. & Tjerbo, Trond (2023). Brukere med særlig høye kostnader i pleie- og omsorgstjenestene – hvem er de, og hva betyr de for kommunale utgifter? Magma forskning og viten. ISSN 1500-0788. 26(5), p. 93–102. doi: 10.23865/magma.v26.1423. Full text in Research Archive Show summary

  Bakgrunn: Det er kjent fra internasjonal litteratur at en liten gruppe tjenestemottakere står for en stor andel av de totale kostnadene i helsetjenestene. Om det finnes en tilsvarende gruppe med høykostnadsbrukere innenfor pleie- og omsorgstjenestene, og hva som eventuelt kjennetegner disse brukerne, er ikke undersøkt i Norge eller andre vestlige land. Mål: Målet for studien er å etablere oversikt over høykostnadsbrukere innenfor de kommunale pleie- og omsorgstjenestene i Norge. Finnes det en liten gruppe av tjenestemottakere som står for en stor del av kostnadene i de kommunale pleie- og omsorgstjenestene? Hvilke grupper representerer de, og hva betyr de for kommunale utgifter? Metode: Analysen gjøres på individdata fra Kommunalt pasientregister (KPR) for 2019. Pasientene med 5 prosent høyest kostnader defineres som brukere med særlig høye kostnader – høykostnadsbrukere. Oddsen for å være i gruppen av høykostnadsbrukere estimeres deretter ved en flernivåanalyse. Resultater: Høykostnadsbrukerne står for 39 prosent av de samlede kostnadene for kommunale pleie- og omsorgstjenester. Gjennomsnittskostnaden for høykostnadsbrukerne er knapt 2,2 millioner kroner. For de øvrige brukerne er gjennom-snittskostnaden vel 186 000 kroner. Det er betydelige forskjeller mellom høykostnadsbrukerne og de øvrige brukerne særlig når det gjelder tjenestebruk, alder og diagnoser. For høykostnadsbrukerne genereres nesten 90 prosent av kostnadene gjennom bruk av hjemmetjenester. Den største kostnaden er forbundet med Praktisk bistand – opplæring (36,2 prosent). Høykostnadsbrukerne er i gjennomsnitt yngre enn de øvrige brukerne (46 år vs. 66 år) og har ofte funksjonshemminger. Konklusjon: En liten gruppe tjenestemottakere står for en stor andel av de samlede kostnadene for pleie- og omsorgstjenester i Norge. Disse brukerne er yngre, hjemmeboende og funksjonshemmede

• Hagen, Terje P. & Tjerbo, Trond (2023). The Causal Effect of Community Hospitals on General Hospital Admissions. Evaluation of a Natural Experiment Using Register Data. International Journal of Integrated Care (IJIC). 23(2). doi: 10.5334/ijic.6515. Full text in Research Archive Show summary

  Background: To reduce overall healthcare costs, several countries have attempted to shift services from specialist to primary care. This was also the main strategy of the Coordination Reform introduced in Norway in 2012. An important part of the reform was the introduction of Municipal Acute Wards (MAWs), a type of community hospital aimed at reducing admissions to general hospitals. The main objective of this paper is to investigate whether the implementation of MAWs had a causal effect on hospital admissions. Methods: Monthly admission rates in total and by age groups for patients admitted with acute or elective conditions at internal medicine or surgical departments were analyzed using panel data regression techniques. We identified causal effects by exploiting the sequential roll out of the MAWs within fixed effect analyses. Our data covered all municipalities from start of 2010 until the end of 2017. Results: The sequential implementation of the MAWs started during the summer of 2012. By the beginning of 2016 close to all municipalities had an operative MAW. The introduction of MAWs significantly reduced acute hospital admissions. The effect was strongest for patients ≥80 years admitted acutely to internal medicine departments. The effects were even stronger if the MAW had a physician on site 24/7 or was located close to a local emergency center. Conclusion: Our findings suggest that this type of intermediate care unit is a viable option to alleviate the burden on hospitals by reducing acute secondary care admission volumes.

• Hilland, Geir Haakon Iversen; Hagen, Terje P. & Martinussen, Pål Erling (2023). Stayin’ alive: The introduction of municipal in-patient acute care units was associated with reduced mortality and fewer hospital readmissions. Social Science and Medicine. ISSN 0277-9536. 326. doi: 10.1016/j.socscimed.2023.115912. Full text in Research Archive Show summary

  Background Integrated care is seen as integral in combating the current and projected resource scarcity in the healthcare systems of developed economies. Previous research finds positive effects from implementing intermediate care but there is a lack of research on how this shift towards care integration has affected traditional quality indicators within healthcare, indicators such as mortality rates and hospital readmissions. We seek to contribute to the discourse by studying how the introduction of intermediate care in the form of municipal acute units (MAUs) in Norway has affected age adjusted mortality rates and hospital readmissions. Data and methods In this retrospective cohort study we utilize yearly population-based registry data from 2010 to 2016, analysed with fixed-effects regressions. Data on the implementation, characteristics and localization of the MAUs were gathered by telephone during the implementation period. Data on mortality rates and hospital readmissions were collected from Statistics Norway and the Norwegian patient registry. Results Our analyses finds that the introduction of MAU was associated with a statistically significant reduction in both aggregated mortality rates and hospital readmission rates. In depth analyses finds that our results are contingent upon the age of the patients treated at the MAUs and the clinical characteristics of the medical units themselves. Conclusion Our findings indicate that the shift towards intermediate care through the introduction of MAUs has increased performance within the public healthcare sector in Norway. Our findings indicate that the introduction of MAU have had a positive public health impact by lowering the mortality and readmission rates for the oldest population cohort in Norway. Our findings suggests that countries with comparatively similar healthcare systems as Norway could achieve similar benefits from implementing intermediate care in the form of somatic medical institutions in the local communities.

• Hagen, Terje P. & Tjerbo, Trond (2023). Vi forbereder oss på «eldrebølgen», men i kommunehelsetjenesten er det en «yngrebølge». Tidsskrift for omsorgsforskning. ISSN 2387-5976. 9(2), p. 92–104. doi: 10.18261/tfo.9.2.8. Full text in Research Archive Show summary

  Bakgrunn: Det er ventet at økningen i andelen eldre vil skape utfordringer for omsorgstjenestene. Kommunalt pasient- og brukerregister (KPR) gir gode muligheter til å analysere bruk av omsorgstjenester og se på variasjoner etteralder. Så langt er denne muligheten ikke fullt utnyttet. I denne artikkelen gjennomfører vi en detaljert analyse av endringer i etterspørselen av kommunale pleie- og omsorgstjenester i perioden fra starten av 2017 til og med 2020 basert på data fra KPR. Metode: Vi benytter enkle beskrivende analyser. Hovedresultater: Nedgangen i pasienter på langtidsopphold i institusjoner har stoppet opp. I analyseperioden observerte vi et stabilt antall pasienter, om lag 33000 per uke. Andelen pasienter over 80 år utgjør om lag 75 prosent av totalen, men er svakt fallende over tid. Det er en økning i antall pasienter i alle aldersgrupper under 80 år. Antall pasienter som har vært i institusjoner på tidsbegrensede opphold og i avlastningsopphold, har økt. Veksten er sterkest i aldersgruppene under 80

• Forster, Rachel Bedenis; Strandberg, Ragnhild Bjarkøy; Tibballs, Katrina Louise Bø; Nøkleby, Kjersti; Berg, Tore Julsrud & Iversen, Tor [Show all 15 contributors for this article] (2022). Cohort profile: Outcomes & Multi-morbidity In Type 2 diabetes (OMIT) - a national registry-based observational cohort with focus on care and treatment of key high-risk groups in Norway. BMJ Open. 12(5). doi: 10.1136/bmjopen-2021-054840. Full text in Research Archive Show summary

  Purpose The ‘Outcomes & Multi-morbidity in Type 2 Diabetes’ (OMIT) is an observational registry-based cohort of Norwegian patients with type 2 diabetes (T2D) established to study high-risk groups often omitted from randomised clinical trials. Participants The OMIT cohort includes 57 572 patients with T2D identified via linkage of Norwegian Diabetes Register for Adults and the Rogaland-Oslo-Salten-Akershus-Hordaland study, both offering data on clinical patient characteristics and drug prescriptions. Subsequently these data are further linked to the Norwegian Prescription Database for dispensed medications, the Norwegian Population Register for data on death and migration, Statistics Norway for data on socioeconomic factors and ethnicity and the Norwegian Directorate of Health for data on the general practices and clinical procedures involved in the care of cohort patients. OMIT offers large samples for key high-risk patient groups: (1) young-onset diabetes (T2D at age <40 years) (n=6510), (2) elderly (age >75 years) (n=15 540), (3) non-Western ethnic minorities (n=9000) and (4) low socioeconomic status (n=20 500). Findings to date On average, patient age and diabetes duration is 67.4±13.2 and 12.3±8.3 years, respectively, and mean HbA1c for the whole cohort through the study period is 7.6%±1.5% (59.4±16.3 mmol/mol), mean body mass index (BMI) and blood pressure is 30.2±5.9 kg/m2 and 135±16.1/78±9.8 mm Hg, respectively. Prevalence of retinopathy, coronary heart disease and stroke is 10.1%, 21% and 6.7%, respectively. Future plans The OMIT cohort features 5784 subjects with T2D in 2006, a number that has grown to 57 527 in 2019 and is expected to grow further via repeated linkages performed every third to fifth year. At the next wave of data collection, additional linkages to Norwegian Patient Registry and Norwegian Cause of Death Registry for data on registered diagnoses and causes of death, respectively, will be performed.

• M.P., Ugarte; Achilleos, Souzana; Quattrocchi, Annalisa; Gabel, John; Hagen, Terje P. & Verstiuk, Olesia (2022). Premature mortality attributable to COVID-19: potential years of life lost in 17 countries around the world, January–August 2020. BMC Public Health. doi: 10.1186/s12889-021-12377-1. Full text in Research Archive Show summary

  Background Understanding the impact of the burden of COVID-19 is key to successfully navigating the COVID-19 pandemic. As part of a larger investigation on COVID-19 mortality impact, this study aims to estimate the Potential Years of Life Lost (PYLL) in 17 countries and territories across the world (Australia, Brazil, Cape Verde, Colombia, Cyprus, France, Georgia, Israel, Kazakhstan, Peru, Norway, England & Wales, Scotland, Slovenia, Sweden, Ukraine, and the United States [USA]). Methods Age- and sex-specific COVID-19 death numbers from primary national sources were collected by an international research consortium. The study period was established based on the availability of data from the inception of the pandemic to the end of August 2020. The PYLL for each country were computed using 80 years as the maximum life expectancy. Results As of August 2020, 442,677 (range: 18–185,083) deaths attributed to COVID-19 were recorded in 17 countries which translated to 4,210,654 (range: 112–1,554,225) PYLL. The average PYLL per death was 8.7 years, with substantial variation ranging from 2.7 years in Australia to 19.3 PYLL in Ukraine. North and South American countries as well as England & Wales, Scotland and Sweden experienced the highest PYLL per 100,000 population; whereas Australia, Slovenia and Georgia experienced the lowest. Overall, males experienced higher PYLL rate and higher PYLL per death than females. In most countries, most of the PYLL were observed for people aged over 60 or 65 years, irrespective of sex. Yet, Brazil, Cape Verde, Colombia, Israel, Peru, Scotland, Ukraine, and the USA concentrated most PYLL in younger age groups. Conclusions Our results highlight the role of PYLL as a tool to understand the impact of COVID-19 on demographic groups within and across countries, guiding preventive measures to protect these groups under the ongoing pandemic. Continuous monitoring of PYLL is therefore needed to better understand the burden of COVID-19 in terms of premature mortality.

• Bjørnelv, Gudrun Maria Waaler; Hagen, Terje P.; Forma, Leena & Aas, Eline (2022). Care pathways at end-of-life for cancer decedents: registry based analyses of the living situation, healthcare utilization and costs for all cancer decedents in Norway in 2009-2013 during their last 6 months of life. BMC Health Services Research. 22(1). doi: 10.1186/s12913-022-08526-w. Full text in Research Archive Show summary

  Background Research on end-of-life care is often fragmented, focusing on one level of healthcare or on a particular patient subgroup. Our aim was to describe the complete care pathways of all cancer decedents in Norway during the last six months of life. Methods We used six national registries linked at patient level and including all cancer decedents in Norway between 2009-2013 to describe patient use of secondary, primary-, and home- and community-based care. We described patient’s car pathway, including patients living situation, healthcare utilization, and costs. We then estimated how cancer type, individual and sociodemographic characteristics, and access to informal care influenced the care pathways. Regression models were used depending on the outcome, i.e., negative binomial (for healthcare utilization) and generalized linear models (for healthcare costs). Results In total, 52,926 patients were included who died of lung (16%), colorectal (12%), prostate (9%), breast (6%), cervical (1%) or other (56%) cancers. On average, patients spent 123 days at home, 24 days in hospital, 16 days in short-term care and 24 days in long-term care during their last 6 months of life. Healthcare utilization increased towards end-of-life. Total costs were high (on average, NOK 379,801). 60% of the total costs were in the secondary care setting, 3% in the primary care setting, and 37% in the home- and community-based care setting. Age (total cost-range NOK 361,363-418,618) and marital status (total cost-range NOK354,100-411,047) were stronger determining factors of care pathway than cancer type (total cost-range NOK341,318- 392,655). When patients died of cancer types requiring higher amounts of secondary care (e.g., cervical cancer), there was a corresponding lower utilization of primary, and home- and community-based care, and vice versa. Conclusion Cancer patient’s care pathways at end-of-life are more strongly associated with age and access to informal care than underlying type of cancer. More care in one care setting (e.g., the secondary care) is associated with less care in other settings (primary- and home- and community based care setting) as demonstrated by the substitution between the different levels of care in this study. Care at end-of-life should therefore not be evaluated in one healthcare level alone since this might bias results and lead to suboptimal priorities.

• Yitbarek, Kiddus; Hurlburt, Sarah; Hagen, Terje P.; Berhane, Melkamu; Abraham, Gelila & Adamu, Ayinengida [Show all 8 contributors for this article] (2021). Inequitable Utilization of Neonatal Health Services in Southwest Ethiopia: The Effects of Socioeconomic Disparities. INQUIRY (INQ). ISSN 0046-9580. 58. doi: 10.1177/00469580211018290. Full text in Research Archive
• Hagen, Terje P. (2021). Er det stordriftsfordeler i sykehus? Praktisk Økonomi & Finans. ISSN 1501-0074. 37(3), p. 233–241. doi: 10.18261/issn.1504-2871-2021-03-06. Full text in Research Archive Show summary

  I Norge er spørsmålet om det er stordriftsfordeler i sykehus aktualisert av to forhold. For det første står landet foran sykehusutbygginger i Mjøsområdet, Drammen, Oslo og på Helgelandskysten. Et grunnleggende tema i debatten har vært om en skal bygge store sykehus eller satse på mindre, men flere enheter. Både i Mjøsområdet og i Oslo ser en i skrivende stund ut til å legge opp til større utbygginger. Den andre saken er den nylig vedtatte fordelingsmodellen mellom staten og de regionale helseforetakene der en kompenserer for ulemper forbundet med størrelse. Det paradoksale er altså at en legger opp til sykehusutbygginger som ifølge den statlige utredningen er ineffektive og som en i neste omgang må kompensere for. I artikkelen går jeg gjennom internasjonal litteratur om temaet og stiller tre spørsmål: Er det stordriftsfordeler i sykehus? Kan eventuelle stordriftsfordeler utløses gjennom sykehussammenslåinger? Hvordan påvirkes kvaliteten i sykehusbehandlingen av sykehussammenslåinger? Artikkelen er ikke en systematisk revy i streng forstand, men en gjennomgang av litteraturen som legger vekt på hvordan analysene av effektivitet og skalaeffekter har endret seg over tid og hvordan disse endringene har påvirket konklusjonene. Avslutningsvis knytter jeg trådene tilbake til den norske debatten.

• Hsu, John; Iversen, Tor; Price, Mary; Moger, Tron Anders; Tevis, Delaney & Hagen, Terje P. [Show all 7 contributors for this article] (2021). Myocardial infarction care among the elderly: Declining treatment with increasing age in two countries. Health Affairs. ISSN 0278-2715. 40(9), p. 1483–1490. doi: 10.1377/hlthaff.2021.00108. Full text in Research Archive Show summary

  The elderly account for the majority of medical spending in many countries, raising concerns about potentially unnecessary spending, especially during the final months of life. Using a well-defined starting point (hospitalization for an initial acute myocardial infarction) with evidence-based postevent treatments, we examined age trends in treatments in the US and Norway, two countries with high levels of per capita medical spending. After accounting for comorbidities, we found marked decreases within both countries in the use of invasive treatments with age (for example, less use of percutaneous coronary interventions and surgery) and the use of relatively inexpensive medications (for example, less use of anticholesterol [statin] drugs for which generic versions are widely available). The treatment decreases with age were larger in Norway compared with those in the US. The less frequent treatment of the oldest of the old, without even use of basic medications, suggests potential age-related bias and a disconnect with the evidence on treatment value. Hospital organization and payment in both countries should incentivize greater equity in treatment use across ages.

• Ambugo, Eliva Atieno; Bruin, Simone R. de; Masana, Lina; MacInnes, Julie; Mateu, Nuri Cayuelas & Hagen, Terje P. [Show all 7 contributors for this article] (2021). A Cross-European Study of Informal Carers’ Needs in the Context of Caring for Older People, and their Experiences with Professionals Working in Integrated Care Settings. International Journal of Integrated Care (IJIC). 21(3). doi: 10.5334/ijic.5547. Full text in Research Archive Show summary

  Introduction: Informal carers are increasingly relied on for support by older people and the health and social care systems that serve them. It is therefore important that health and social care professionals are knowledgeable about and responsive to informal carers’ needs. This study explores informal carers’ own needs within the context of caregiving; and examines, from the informal carers’ perspective, the extent to which professionals assess, understand and are responsive to informal carers’ needs. Methods: We interviewed (2016–2018) 47 informal carers of older people being served by 12 integrated care initiatives across seven countries in Europe. The interviews were thematically coded inductively and analysed. Results: Informal carers reported that professionals treated them with respect and made efforts to assess and respond to their needs. However, even though professionals encouraged informal carers to look after themselves, informal carers’ needs (e.g., for respite, healthcare) were insufficiently addressed, and informal carers tended to prioritize older people’s needs over their own. Discussion and conclusion: Informal carers need better support in caring for their own health. Health professionals should have regular contact with informal carers and proactively engage them in ongoing needs assessment, setting action plans for addressing their needs, and identifying/accessing appropriate support services. This will be important if informal carers are to continue their caregiving role without adverse effects to themselves.

• Hellesø, Ragnhild & Hagen, Terje P. (2021). Samhandlingsreforma- kva fungerte, kva må gjerast vidare? In Botten, Grete Synøve (Eds.), Mangfold og engasjement i ti år. Institutt for helse og samfunn ved Universitetet i Oslo 2010-2020.. Norwegian Medical Society. ISSN 9788292871768. p. 92–98. Full text in Research Archive
• Achilleos, Souzana; Quattrocchi, Annalisa; Gabel, John; Heraclides, Alexandros; Kolokotroni, Ourania & Constantinou, Constantina [Show all 46 contributors for this article] (2021). Excess all-cause mortality and COVID-19-related mortality: a temporal analysis in 22 countries, from January until August 2020. International Journal of Epidemiology. ISSN 0300-5771. doi: 10.1093/ije/dyab123. Full text in Research Archive
• Fosse, Rina Moe; Ambugo, Eliva Atieno; Moger, Tron Anders; Hagen, Terje P. & Tjerbo, Trond (2021). Does rehabilitation setting influence risk of institutionalization? A register-based study of hip fracture patients in Oslo, Norway. BMC Health Services Research. 21(1), p. 1–14. doi: 10.1186/s12913-021-06703-x. Full text in Research Archive Show summary

  Background: Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients’ subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6–12 months from the index admission). Methods: Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients’ age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo’s boroughs to control for supply-side and unobserved effects. Results: The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23–0.76) of living in a nursing home at 6–12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF. Conclusions: The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

• Lette, Manon; Ambugo, Eliva; Hagen, Terje P.; Nijpels, Giel; Baan, Caroline & Bruin, Simone De (2020). Addressing safety in integrated care programs for older adults living at home: A systematic scoping review. BMC Geriatrics. doi: 10.1186/s12877-020-1482-7. Full text in Research Archive
• Häkkinen, Unto; Goude, Fanny; Hagen, Terje P.; Kruse, Marie; Moger, Tron Anders & Peltola, Mikko [Show all 7 contributors for this article] (2020). A performance comparison of patient pathways in Nordic capital areas – a pilot study for ischaemic stroke patients. Scandinavian Journal of Public Health. ISSN 1403-4948. doi: 10.1177/1403494819863523. Full text in Research Archive
• Ambugo, Eliva & Hagen, Terje P. (2019). Effects of introducing a fee for inpatient overstays on the rate of death and readmissions across municipalities in Norway. Social Science and Medicine. ISSN 0277-9536. 230, p. 309–317. doi: 10.1016/j.socscimed.2019.04.006. Full text in Research Archive Show summary

  The Norwegian healthcare coordination reform (Samhandlingsreformen) was implemented from January 1, 2012. In addition to providing municipalities with funding to strengthen their health infrastructure, it required municipalities to pay hospitals a daily fee for patients who, having been declared ready for discharge and in need of municipal health services, were not received by the municipalities on time. This study examines the effects of the reform on the rate of death and readmissions occurring within 60 days of hospitalization. We use aggregated municipal data for years 2009, 2010, 2012-2014 (N=1646) for Norwegian patients (age 18+) hospitalized in the same years for COPD/asthma, heart failure, hip fracture, and stroke. We stratify our analyses of the municipal data by these patient groups. Our linear regression models test for moderated (interaction) effects whereby associations between the reform and the rate of death and readmissions vary by whether or not patients were classified as ready for discharge and in need of follow-up care in the municipality. The models adjust for municipal sociodemographic and health characteristics. We found no statistically significant moderated effects of the reform across the patient groups, except for patients with stroke (b=.027, SE=.109, p<.05). Specifically, compared to the pre-reform period (2009 2010), the post-reform period (2012-2014) was associated with a higher rate of readmissions at high predicted values of needing follow-up care. Although our analyses of municipal data suggest that patients with stroke are vulnerable to the reform and its incentive scheme, there is no strong evidence overall to suggest that the Norwegian healthcare coordination reform is functioning in a manner that exacerbates the risk of death and readmissions.

• Moger, Tron Anders; Häkkinen, Unto & Hagen, Terje P. (2018). Higher mortality among ACS patients in Finland than in Norway: Do differences in acute services and scale effects in hospital treatment explain the variation? Nordic Journal of Health Economics. ISSN 1892-9729. 7. doi: 10.5617/njhe.4834. Full text in Research Archive Show summary

  Mortality following hospital treatment in Finland and Norway is similar for major diseases, with acute coronary syndrome (ACS) as an important exception. For ACS, the mortality is significantly higher in Finland than in Norway. We study whether a decentralized structure with reduced emergency preparedness and smallscale production in Finland vs. a centralized structure with large percutaneous coronary intervention (PCI) departments performing acute services 24/7 in Norway explains the country differences in mortality. For patients discharged with acute myocardial infarction (International Classification of Diseases - ICD-10 I21 and I22) and unstable angina pectoris (ICD-10 I 20.0), data from the hospital discharge registers for 1 Jan. 2009–30 Nov. 2014 was linked with socio-demographic and regional variables, variables describing distances to hospitals, and with data from causes of death registers in Norway and Finland. Variables relating to hospital system and organization of care were included as independent variables in logistic regression analyses. Marginal mortality differences between the countries for different categories of the variables are presented separately for ST-segment elevation myocardial infarction (STEMI) and for other ACS patients. In Finland, 36% of STEMI patients and 25% of other ACS patients were admitted to hospitals having an emergency PCI service. The corresponding numbers for Norway were 77% and 66%. However, the percentage of patients receiving PCI within one day was similar (STEMI: Norway 54% vs. Finland 56%, p < 0.001), as was the distribution of PCIs performed during weekends (28% vs. 26%, p = 0.02). The short term mortality was a little lower in Norway for STEMI patients (30-day mortality: 10% vs. 12%, p < 0.001; 365-day mortality: 18% vs. 18%, p = 0.48), while markedly lower for other ACS (30-day mortality: 6% vs. 10%, p < 0.001; 365-day mortality: 14% vs. 20%, p < 0.001). After adjusting for individual and regional variables, the mortality was found to be 2–4% lower in Norway within most categories of the hospital system and organization of care variables in all analyses. As such, we were not able to explain the mortality differences by the hospital system and organization of care variables. Rather, the explanation seems to have other sources.

• Häkkinen, Unto; Hagen, Terje P. & Moger, Tron Anders (2018). Performance comparison of hip fracture pathways in two capital cities: Associations with level and change of integration. Nordic Journal of Health Economics. ISSN 1892-9729. 7. doi: 10.5617/njhe.4836. Full text in Research Archive Show summary

  Finland and Norway have health care systems that have a varying degree of vertical integration. In Finland the financial responsibility for all patient treatment is placed at the municipal level, while in Norway the responsibility for patients is divided between the municipalities (primary and long-term care) and state-owned hospitals. From 2012, the Norwegian system became more vertically integrated following the introduction of the Coordination Reform. The aim of the paper is to analyse the associations between different modes of integration and performance indicators. The data included operated hip fracture patients from the years 2009– 2014 residing in the cities of Oslo and Helsinki. Data from routinely collected national registers, also including data from primary health and long-term-care services, were linked. Performance indicators were compared at baseline (before the Coordination Reform, i.e., 2009–2011), and trends were described and analysed by difference-in-difference methods. The baseline study indicated that hip fracture patients in Oslo, compared with those in Helsinki, had longer stays in acute hospitals. They used less institutional care outside of hospitals as well as more GP services and fewer other outpatient services. Mortality was lower, and the probability of being discharged to home within 90 days from the index day was higher. After the Coordination Reform, the length of stay in hospital was shorter and the length of the first institutional episode in Oslo was longer than before the Reform, demonstrating that the shorter hospital stays were more than compensated for by longer stays in long-term-care institutions. The number of patients institutionalised 90 days from the index day increased and the number of patients discharged to home within 90 days from the index day decreased in Oslo after the Reform while the opposite trends were observed in Helsinki. After the Reform, the performance differences between the two regions had decreased.

• Holom, Geir Hiller; Alexandersen, Nina; Goldhaber-Fieber, Jeremy D. & Hagen, Terje P. (2018). Which patients receive surgery in for-profit and non-profit hospitals in a universal health system? An explorative register-based study in Norway. BMJ Open. 8(6), p. 1–10. doi: 10.1136/bmjopen-2017-019780. Full text in Research Archive Show summary

  Objectives To compare the socioeconomic status (SES) and case-mix among day surgical patients treated at private for-profit hospitals (PFPs) and non-profit hospitals (NPs) in Norway, and to explore whether the use of PFPs in a universal health system has compromised the principle of equal access regardless of SES. Design A retrospective, exploratory study comparing hospital types using the Norwegian Patient Register linked with socioeconomic data from Statistics Norway by utilising Norwegian citizens’ personal identification numbers. Setting The Norwegian healthcare system. Population All publicly-financed patients in five Norwegian metropolitan areas having day surgery for meniscus (34 100 patients), carpal tunnel syndrome (15 010), benign breast hypertrophy (6 297), or hallux valgus (2 135) from 2009–2014. Primary outcome measure Having surgery at a PFP or NP. Results Across four unique procedures, the adjusted odds ratios (aORs) for using PFPs were generally lower for the lowest educational level (0.77–0.87) and the lowest income level (0.68–0.89), though aORs were not always significant. Likewise, comorbidity and previous hospitalisation had lower aORs (0.62-0.95; 0.44-0.97, respectively) for having surgery at PFPs across procedures, though again aORs were not always significant. No clear patterns emerged with respect to age, gender, or higher levels of income and education. Conclusions The evidence from our study of four procedures suggests that equal access to PFPs compared to NPs for those patients at the lowest education and income levels may be compromised, though further investigations are needed to generalise these findings across more procedures and probe causal mechanisms and appropriate policy remedies. The finding that comorbidity and previous hospitalisation had lower odds of treatment at PFPs indicates that NPs play an essential role for more complex patients, but raises questions about patient preference and cream skimming.

• Swanson, Jayson O.; Vogt, Verena; Sundmacher, Leonie; Hagen, Terje P. & Moger, Tron Anders (2018). Continuity of care and its effect on readmissions for COPD patients: A comparative study of Norway and Germany. Health Policy. ISSN 0168-8510. 122(7), p. 737–745. doi: 10.1016/j.healthpol.2018.05.013. Full text in Research Archive Show summary

  Background This study compares continuity of care between Germany – a social health insurance country, and Norway – a national health service country with gatekeeping and patient lists for COPD patients before and after initial hospitalization. We also investigate how subsequent readmissions are affected. Methods Continuity of Care Index (COCI), Usual Provider Index (UPC) and Sequential Continuity Index (SECON) were calculated using insurance claims and national register data (2009–14). These indices were used in negative binomial and logistic regressions to estimate incident rate ratios (IRR) and odds ratios (OR) for comparing readmissions. Results All continuity indices were significantly lower in Norway. One year readmissions were significantly higher in Germany, whereas 30-day rates were not. All indices measured one year after discharge were negatively associated with one-year readmissions for both countries. Significant associations between indices measured before hospitalization and readmissions were only observed in Norway – all indices for one-year readmissions and SECON for 30-day readmissions. Conclusion Our findings indicate higher continuity is associated with reductions in readmissions following initial COPD admission. This is observed both before and after hospitalization in a system with gatekeeping and patient lists, yet only after for a system lacking such arrangements. These results emphasize the need for policy strategies to further investigate and promote care continuity in order to reduce hospital readmission burden for COPD patients.

• Tjerbo, Trond & Hagen, Terje P. (2018). The health policy pendulum: Cost control vs activity growth. International Journal of Health Planning and Management. ISSN 0749-6753. 33(1), p. e67–e75. doi: 10.1002/hpm.2407. Full text in Research Archive Show summary

  Background: Cost containment is a major policy challenge and one of the key drivers of health care reform. In this article, we focus on the role cost control has played as a reform driver in the Norwegian hospital sector between 1980 and 2014. Methods: We use data on aggregate expenditure as well as on activity changes from year to year. We also use qualitative data for illustrative purposes. Results: We identify 4 phases in the period 1980 to 2014: two where activity increases have dominated the agenda and 2 where cost control has been emphasized. The desire to either increase activity or improve cost control has been important reform drivers. Conclusion: Cost control has been a major reform motivator in the period, and some of the policies aimed towards achieving cost control have been successful. But as cost control is achieved, waiting lists and popular dissatisfaction increase and new policies are implemented to increase activity. The final version of this research has been published in International Journal of Health Planning and Management. © 2017 Wiley

• Holom, Geir Hiller & Hagen, Terje P. (2017). Quality differences between private for-profit, private non-profit and public hospitals in Norway: a retrospective national register based study of acute readmission rates following total hip and knee arthroplasty. BMJ Open. doi: 10.1136/bmjopen-2016-015771. Full text in Research Archive Show summary

  Objectives To compare the quality of care—using unplanned acute hospital readmissions as a quality measure—among patients treated at private for-profit hospitals (PFPs), private non-profit hospitals (PNPs) and public hospitals (PUBs) in Norway. Design A retrospective comparative study using the Norwegian Patient Register. Readmissions were evaluated by logistic regressions both using adjustment for various patient-level and other covariates, and a two-stage model using distance as an instrumental variable. Setting The Norwegian healthcare system. Population All publicly financed patients having primary total hip (37 897 patients) or primary total knee arthroplasty (25 802 patients) at one of the three hospital types from 2009 to 2014. Primary outcome measure 30-day unplanned acute hospital readmission rate. Results We found highest readmission rates among PUBs and lowest among PFPs, for both procedures. However, the patients were on average more than 2 years younger at PFPs. PFPs also treated the least severe patients, while PUBs treated the most severe. Using adjustment for various patient-level and other covariates, compared to PUBs, both PFPs and PNPs had lower odds of readmission following both procedures. However, using the instrumental variable method, the only significant difference found was a lower odds of readmission at PNPs among hip patients when compared with PUBs. No patients in our data set were readmitted to PFPs, those originally treated at PFPs were readmitted to either PNPs or PUBs, and PUBs received most of the readmitted patients across hospital types. Conclusions Quality differences between hospital types were small; however, PNPs had significantly lower readmission rates compared with PUBs among patients having total hip arthroplasty. PUBs received the larger part of the readmitted patients across hospital types and thus play an essential role in the care of more complex patients and for readmissions, regardless of any quality differences.

• Johannessen, Karl-Arne; Kittelsen, Sverre A.C. & Hagen, Terje P. (2017). Assessing physician productivity following Norwegian hospital reform: A panel and data envelopment analysis. Social Science and Medicine. ISSN 0277-9536. 175, p. 117–126. doi: 10.1016/j.socscimed.2017.01.008. Full text in Research Archive Show summary

  Background: Although health care reforms may improve efficiency at the macro level, less is known regarding their effects on the utilization of health care personnel. Following the 2002 Norwegian hospital reform, we studied the productivity of the physician workforce and the effect of personnel mix on this measure in all nineteen Norwegian hospitals from 2001 to 2013. Methods: We used panel analysis and non-parametric data envelopment analysis (DEA) to study physician productivity defined as patient treatments per full-time equivalent (FTE) physician. Resource variables were FTE and salary costs of physicians, nurses, secretaries, and other personnel. Patient metrics were number of patients treated by hospitalization, daycare, and outpatient treatments, as well as corresponding diagnosis-related group (DRG) scores accounting for differences in patient mix. Research publications and the fraction of residents/FTE physicians were used as proxies for research and physician training. Results: The number of patients treated increased by 47% and the DRG scores by 35%, but there were no significant increases in any of the activity measures per FTE physician. Total DRG per FTE physician declined by 6% (p < 0.05). In the panel analysis, more nurses and secretaries per FTE physician correlated positively with physician productivity, whereas physician salary was neutral. In 2013, there was a 12%–80% difference between the hospitals with the highest and lowest physician productivity in the differing treatment modalities. In the DEA, cost efficiency did not change in the study period, but allocative efficiency decreased significantly. Bootstrapped estimates indicated that the use of physicians was too high and the use of auxiliary nurses and secretaries was too low. Conclusions: Our measures of physician productivity declined from 2001 to 2013. More support staff was a significant variable for predicting physician productivity. Personnel mix developments in the study period were unfavorable with respect to physician productivity.

• Hagen, Terje P. & Tingvold, Laila (2017). Planning future care services: Analyses of investments in Norwegian municipalities. Scandinavian Journal of Public Health. ISSN 1403-4948. 46(4), p. 495–502. doi: 10.1177/1403494817730996. Full text in Research Archive Show summary

  Aims: To analyse whether the Norwegian Central Government’s goal of subsidizing 12,000 places in nursing homes or sheltered housing using an earmarked grant was reached and to determine towards which group of users the planned investments were targeted. Methods: Data from the investment plans at municipal level were provided by the Norwegian Housing Bank and linked to variables describing the municipalities’ financial situation as well as variables describing the local needs for services provided by Statistics Norway. Using regression analyses we estimated the associations between municipal characteristics and planned investments in total and by type of care place. Results: The Norwegian Central Government reached its goal of giving subsidies to 12,000 new or rebuilt places in nursing homes and sheltered housing. A total of 54% of the subsidies (6878 places) were given to places in nursing homes. About 7500 places were available by the end of the planning period and the rest were under construction. About 50% of the places were planned for user groups aged <67 years and 23% of the places for users aged <25 years. One-third of the places were planned for users with intellectual disabilities. Investments in nursing homes were correlated with the share of the population older than 80 years and investments in sheltered houses were correlated with the share of users with intellectual disabilities. Conclusions: Earmarked grants to municipalities can be adequate measures to affect local resource allocation and thereby stimulate investments in future care. With the current institutional setup the municipalities adapt investments to local needs.

• Hagen, Terje P.; Holom, Geir Hiller & Ameyu, Kebebew Negera (2017). Outsourcing day surgery to private for-profit hospitals: the price effects of competitive tendering. Health Economics, Policy and Law. ISSN 1744-1331. 13, p. 50–67. doi: 10.1017/S1744133117000019. Full text in Research Archive Show summary

  Setting prices for elective patient treatments in private for-profit (PFP) hospitals in traditional tax-funded health systems is challenging since both the organisation of these hospitals and the tasks they perform differ considerably from what we find in public hospitals. From the year 2000, Norway became one of a few countries to gradually implement a procurement system based on competitive tendering when outsourcing elective surgery. In this study we analyse the effect of introducing competitive tendering on the prices paid to PFP hospitals. Pricing data were collected from the formal contracts awarded to PFP hospitals and defined in terms of both absolute and relative prices. We found that PFP hospitals performed day surgeries at markedly lower prices than public hospitals and that competitive tendering triggered the price reduction. We speculate that the PFP hospitals’ lack of acute services, less severe patient population, reduced teaching responsibilities and ability to streamline production, as well as other factors, explain the lower prices at PFP hospitals.

• Alexandersen, Nina; Hagen, Terje P. & Kaarbøe, Oddvar Martin (2017). Hvilke bedrifter kjøper private helseforsikringer i Norge? Samfunnsøkonomen. ISSN 1890-5250. 1, p. 31–38. Full text in Research Archive Show summary

  I underkant av 500 000 personer har private helseforsikringer i Norge, de fleste gjennom arbeidsgiverfinansierte kollektive ordninger. Forsikringene skal primært gi raskere tilgang til spesialisthelsetjenester. Vi bruker data fra en spørreundersøkelse supplert med registerdata fra Brønnøysundregistrene og analyserer sannsynligheten for å ha privat helseforsikring. Vi finner at sannsynligheten for private helseforsikringer øker med antall ansatte og med andel menn i bedriften, men reduseres med sykefravær på næringsnivå. Arbeidsgivers avgjørelse om å kjøpe private helseforsikringer er påvirket av ansattes preferanser og arbeidsgivers oppfatning om at private helseforsikringer kan brukes som rekrutteringsstrategi. I gjennomsnitt er bedriftene fornøyd/veldig fornøyd med det medisinske tilbudet som gis gjennom private helseforsikringer.

• Hagen, Terje P.; Iversen, Tor & Moger, Tron Anders (2016). Risikojustering ved måling av predikert dødelighet etter hjerteinfarkt. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 136(5), p. 423–427. doi: 10.4045/tidsskr.13.1292. Full text in Research Archive
• Hagen, Terje P. & Melberg, Hans Olav (2016). Liggetider og reinnleggelser før og etter Samhandlingsreformen. Tidsskrift for omsorgsforskning. ISSN 2387-5976. 2(2), p. 143–158. doi: 10.18261/issn.2387-5984-2016-02-09. Full text in Research Archive
• Yin, Jun; Dahl, Fredrik Andreas; Hagen, Terje P. & Lurås, Hilde (2016). The influence of changes in activity-based financing on hospital readmissions for the elderly. Nordic Journal of Health Economics. ISSN 1892-9729. 4(2), p. 72–81. doi: 10.5617/njhe.992. Full text in Research Archive
• Swanson, Jayson O. J; Alexandersen, Nina & Hagen, Terje P. (2016). Førte opprettelsen av kommunale akutte døgnenheter til færre innleggelser ved somatiske sykehus? Tidsskrift for omsorgsforskning. ISSN 2387-5976. 2(2), p. 125–134. doi: 10.18261/issn.2387-5984-2016-02-07. Full text in Research Archive Show summary

  I Følge helse- og omsorgstjenesteloven av 2011 skal kommunene tilby heldøgns medisinsk akuttbehandling fra 1. januar 2016. Målet med tilbudet som er kalt kommunal øyeblikkelig hjelp døgnenheter (ØDH), er å redusere antall innleggelser ved sykehusene særlig for den eldre befolkningen. I notatet analyseres om etablering av ØDH-er faktisk har påvirket antall innleggelser ved sykehusene. Vi har hentet inn data om antall innleggelser fra Norske paientregister, data om demografiske variable og data om det kommunale tilbudet av tjeneste utover ØHD-ene fra Statistisk sentralbyrå og data om tidspunkt for etablering av ØHD-ene fra kommunene. Data er analysert som et panel med faste effekter for kommune. Konklusjonene er at innføring av ØDH-ene har hatt effekt, men også at effektene varierer betydelig med hvordan ØDH-ene er organisert. I gjennomsnitt finner vi effekter av innføring av ØDH-er på innleggelser for pasienter over 80 år på knapt (minus) 2%. Det ØDH-ene som er samlokalisert med legevekt og som har god legeberedskap som har effekter. ØDH-er som har annen organisering enn dette har i gjennomsnitt ingen effekt, men det er store variasjoner på kommunenivå.

• Swanson, Jayson O. J & Hagen, Terje P. (2016). Reinventing the community hospital: A retrospective population-based cohort study of a natural experiment using register data. BMJ Open. 6:e012892(12). doi: 10.1136/bmjopen-2016-012892. Full text in Research Archive Show summary

  Objectives To investigate whether implementation of municipal acute bed units (MAUs) resulting from the Norwegian Coordination Reform (2012) was associated with reductions in hospital admissions, particularly for the elderly. Design A municipality-based retrospective comparative cohort study using monthly population-based registry data analysed with fixed-effects log–log regressions. Setting Norwegian municipalities and hospitals. Population All patients admitted to secondary hospital care in Norway between 2010 and 2014, excluding psychiatric admissions, with additional focus on admission type and elderly age subgroups. Main outcome measures Monthly admission rates in total and by age group for all patients, patients admitted with acute conditions and with acute conditions at internal medicine departments. Results The introduction of MAUs was associated with a small yet significant overall negative effect on hospital admissions. The reduction in all admissions was significant for the entire population (−1.2%, 95% CI −2.0% to −0.0%) and slightly stronger for those aged 80 years and above (−1.9%, 95% CI −3.0% to −1.0%). The more detailed analysis of the elderly population aged 80 years and above revealed that effects were affected by the institutional characteristics of the MAUs. The significant effects ranged between −1.6% and −8.6%, depending on the availability of physicians on duty at the MAUs, the MAUs location or combinations thereof. Conclusions Introduction of MAUs following implementation of the Norwegian Coordination Reform in 2012 was associated with a significant reduction in hospital admissions primarily for the elderly. Our findings suggest that this type of intermediate care is a viable option in an effort to alleviate the burden on hospitals by reducing the acute secondary care admission volume. Further examinations focused on cost-effectiveness, health status of patients, number of patients treated at the MAUs and comparing other intermediate care alternatives would all add important perspectives to the issue.

• Mishra, Vinod Kumar; Fiane, Arnt E; Winsnes, Benny Adam; Geiran, Odd; Sørensen, Gro & Hagen, Terje P. [Show all 7 contributors for this article] (2016). Cardiac Replacement Therapies: Outcomes and Costs for Heart Transplantation versus Circulatory Assist. Scandinavian Cardiovascular Journal. ISSN 1401-7431. 51(1), p. 1–7. doi: 10.1080/14017431.2016.1196826. Full text in Research Archive

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• Fiva, Jon H.; Hagen, Terje P. & Sørensen, Rune Jørgen (2026). Kommunal organisering. Universitetsforlaget. ISBN 9788215076249. 241 p. Full text in Research Archive Show summary

  Kommunal organisering er det norske standardverket om kommuner, fylkeskommuner og stat-kommune-relasjoner. Boken både gir en analytisk gjennomgang og en helhetlig beskrivelse av hvordan kommunesektoren fungerer - og hvilke valg som vil forme den i årene som kommer. I 9. utgave (2026) er boken fullstendig revidert og oppdatert. Kommunesektoren står midt i en periode med store strukturelle endringer: aldring i befolkningen, knapphet på arbeidskraft, økt statlig styring og press på generalistkommuneprinsippet. Denne utgaven gir leseren verktøyene som trengs for å forstå - og analysere - disse utviklingstrekkene. Nytt i 9. utgave: Et helt nytt kapittel om kommunal økonomistyring, som analyserer samspillet mellom stat og kommune, vertikal fiskal ubalanse og risikoen for myke budsjettskranker. Et nytt avsluttende kapittel om alternativer for framtiden, der sentrale veivalg - kommunesammenslåing, interkommunalt samarbeid og oppgavedifferensiering - drøftes systematisk. Oppdaterte analyser av kommunereformen og endringer i kommunestrukturen. Nye drøftinger av statlig styring gjennom rettigheter, standarder og øremerking, og hvordan dette gradvis binder opp kommunenes handlingsrom. En grundig analyse av demografiske endringer og arbeidskraftmangel, og hva dette betyr for tjenestetilbud og organisering. Alle figurer og tabeller er oppdatert med nyeste tilgjengelige data. Boken gir leseren en grunnleggende forståelse av hvordan organisasjonsdesign i offentlig sektor påvirker effektivitet, likeverdige tjenester og lokaldemokratiets vitalitet. Kommunal organisering er en sentral lærebok på både bachelor- og masternivå og et uunnværlig referanseverk for alle som arbeider med, forsker på eller tar beslutninger om norsk kommuneforvaltning.

• Berg, Ole Trond; Hagen, Terje P.; Gjefsen, Hege Marie; Godager, Geir; Hart, Rannveig Kaldager & Kinge, Jonas Minet [Show all 13 contributors for this article] (2026). Organisering og finansering av helsetjenester. Fagbokforlaget. ISBN 9788245061505. 414 p. doi: 10.55669/oa1809. Full text in Research Archive Show summary

  Boken gir en bred innføring i organisering og finansiering av helsetjenester, med vekt på norske forhold. Den innledende bolken omfatter kapitler om helsetjenestesystemer og forsikringsordninger, betalingssystemer og demografiske endringer. I de følgende bolkene brukes de grunnleggende begrepene til å beskrive og analysere kommunehelsetjenesten og spesialisthelsetjenesten, samt samhandlingen mellom de to nivåene. Enkelte policy-orienterte temaer, som effektivitet og likhet i tilbudet, analyseres i egne kapitler. Den avsluttende bolken er viet komparativ helsepolitikk, med beskrivelser av land med sosialforsikringsordninger og private helseforsikringer. Utviklingen av EUs helsepolitikk beskrives i et eget kapittel. Bokens underliggende perspektiv er at organisering og finansiering er virkemidler i offentlig helsepolitikk. Dette er instrumenter som kan brukes til å redusere ulikhet i tjenestetilbudet, øke effektiviteten og heve kvaliteten. Boken inneholder oppdatert kunnskap om reformer og piloter fra de siste tiårene, også reformer i andre land som har relevans for norske forhold.

• Fiva, Jon H.; Hagen, Terje P. & Sørensen, Rune Jørgen (2021). Kommunal organisering. Universitetsforlaget. ISBN 9788215055381. 247 p. Full text in Research Archive

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• Anthun, Kjartan Sarheim & Hagen, Terje P. (2025). Sykehusenes kostnadsnivå før og etter investeringer i bygningsmassen. Full text in Research Archive
• Hagen, Terje P. (2025). Finsk, dansk, svensk eller norsk løsning? Aktuelle endringer i de nordiske landenes helsetjenestesystemer. Overlegen. ISSN 1503-2663. Full text in Research Archive
• Hagen, Terje P. (2024). Health care for aging populations: Better health, better aging. Full text in Research Archive
• Hagen, Terje P. (2024). Brukerne blir yngre, psykiske lidelser øker. Full text in Research Archive
• Hagen, Terje P. (2024). Primærhelseteam. Full text in Research Archive
• Hagen, Terje P. (2024). Årsaker til kostnadsvekst i pleie- og omsorgssektoren. Full text in Research Archive
• Hagen, Terje P. (2024). Finansiering av sykehusene – hva blir veien videre? Full text in Research Archive
• Hagen, Terje P.; Aarflot, Morten & Tjerbo, Trond (2024). Analyzing the Impact of Reduced Hospital Stays on Mortality in Primary Care Settings with Variation in Nursing Home Capacity: An Observational Study of Hip Fracture Patients from 2010-2019. Full text in Research Archive
• Hagen, Terje P. (2024). Helse Nord - bølle, strateg eller lasaron? Full text in Research Archive
• Aas, Eline; Godager, Geir; Hagen, Terje P.; Häkkinen, Unto; Karlsson, Martin & Kittelsen, Sverre [Show all 8 contributors for this article] (2023). Advancing and Inspiring Health Economics: A Special Issue in Honor of Tor Iversen. Nordic Journal of Health Economics. ISSN 1892-9729. 6(1), p. 1–5. doi: 10.5617/njhe.10299. Full text in Research Archive Show summary

  Professor Tor Iversen is a distinguished and highly respected health economist who has made significant contributions to the field of health economics. With this special issue, we celebrate his work.

• Hagen, Terje P. & Iversen, Tor (2023). Helse­tjenestene – og det permanente endringsbehovet. Magma forskning og viten. ISSN 1500-0788. 26(5), p. 70–72. doi: 10.23865/magma.v26.1420. Full text in Research Archive
• Bjørnelv, Gudrun Maria Waaler; Aas, Eline; Aaltonen, Mari; Hagen, Terje P. & Forma, Leena (2022). Place of living during end-of-life according to cause of death: a comparative analysis from Finland and Norway. Full text in Research Archive
• Hagen, Terje P.; Forma, Leena & Aas, Eline (2021). En komparativ analyse av sammensetningen av helsetjenester, bosituasjon og totale helsetjenestekostnader for personer med kreft ved livets slutt. Full text in Research Archive
• Bjørnelv, Gudrun Maria Waaler; Hagen, Terje P.; Forma, Leena & Aas, Eline (2021). Living situation, healthcare utilization and costs at end-of-life for cancer patients in Norway. Full text in Research Archive
• Bjørnelv, Gudrun Maria Waaler; Aas, Eline; Aaltonen, Mari; Hagen, Terje P. & Forma, Leena (2021). Place of living during end-of-life according to cause of death: a comparative analysis from Finland and Norway. Full text in Research Archive
• Bjørnelv, Gudrun Maria Waaler; Forma, Leena; Hagen, Terje P. & Aas, Eline (2021). En komparativ analyse av sammensetningen av helsetjenester, bosituasjon og totale helsetjenestekostnader for personer med kreft ved livets slutt. Full text in Research Archive
• Hagen, Terje P. (2021). De første ti årene og veien videre - en samtale. [Journal]. Michael. Full text in Research Archive
• Hagen, Terje P. (2021). Ti år - og med livet foran seg! Michael. ISSN 1893-9651. 18, p. 9–12. Full text in Research Archive
• Hagen, Terje P. (2021). Effects of municipal acute wards on hospital admissions: Evaluation of a natural experiment using register data. Full text in Research Archive Show summary

  Objectives: Norway introduced municipal acute wards (MAWs) as part of the Coordination Reform in 2012 to reduce the number of patients admitted to hospitals. The main objective of the paper is investigate whether implementation of AMUs had a causal effect on hospital admissions. Methods: We analyzed monthly admission rates in total and by age group for patients admitted with acute and elective conditions at internal medicine and surgical departments by panel data regression technics. Identification of the causal effects were made possible by utilizing the sequential implementation of the MAW. Our data covered all municipalities for the period from 2010 until the end of 2017. Preliminary results: The sequential implementation of the MAWs started summer 2012. By the beginning of 2016 close to all municipalities had an MAW up and running. The introduction of MAWs was associated with a significant reduction in acute hospital admissions. The effect was strongest for patients above 80 years of age admitted acutely to internal medicine departments. The effects were even stronger if the MAW had physician on duty 24/7 or were located close to a local emergency center. Conclusion: Our findings suggest that this type of intermediate care is a viable option in an effort to alleviate the burden on hospitals by reducing acute secondary care admission volume.

• Hagen, Terje P. (2020). Innovation prosjects in Health Region South-East. Full text in Research Archive
• Hagen, Terje P. (2018). Ekspertutvalget: Nye oppgaver til fylkeskommunene. Plan. p. 6–11. Full text in Research Archive
• Hagen, Terje P. (2018). Privatisering av helsetjenester i Norden - hovedkonklusjoner. Full text in Research Archive
• Lehto, Juhani S. & Hagen, Terje P. (2018). HEALTH AND SOCIAL CARE SYSTEM REFORM IN FINLAND perspectives on private insurance and private hospitals. Full text in Research Archive
• Hagen, Terje P. (2017). Privatisering på norsk. Anbudskonkurranser, seleksjon og kvalitet i en skattefinansiert helsetjeneste. Full text in Research Archive
• Holom, Geir Hiller; Alexandersen, Nina & Hagen, Terje P. (2017). Which patients receive surgery in for-profit and non-profit hospitals in a universal Health system? An explorative register-based study. Full text in Research Archive
• Moger, Tron Anders; Häkkinen, Unto & Hagen, Terje P. (2017). Higher mortality among ACS patients in Finland than in Norway: Do differences in acute preparedness and scale effects in hospital treatment explain the variation? Full text in Research Archive Show summary

  Background: Mortality differences following hospital treatment in Finland and Norway are similar for major diseases with acute coronary syndrome (ACS) as an important exception. For ACS, mortality in Finland is significantly higher than in Norway. Objective: To study whether the differences in the organization of the PCI facilities, a decentralized structure with reduced emergency preparedness and small scale production in Finland vs. a centralized structure with large PCI departments performing acute services 24/7 in Norway, add to the explanations of country differences in 30 and 365 day all-cause mortality for patients hospitalized with ACS (acute myocardial infarction or unstable angina pectoris). Data and methods: Data for patients discharged with acute myocardial infarction (ICD 10 I21 and I22) and unstable angina pectoris (ICD 10 I 20.0) from the hospital discharge registers in 2009-2014 was linked with socio-demographic variables, variables describing distances to hospitals and causes of death registers in Norway and Finland. The variables of main interest, emergency preparedness of PCI and the volume of ACS patients at hospital level were included as independent variables in logistic regression analyses. Preliminary results: Across all years combined, Norway had lower 30 and 365 days mortality (7% vs 11%, p<0.001 and 14% vs 20%, p<0.001). However, differences for STEMI patients were smaller (30 days: 10% vs 12%, p<0.001, 365 days: 17% vs 18%, p=0.01) than for non-STEMI, undefined and unstable angina patients (30 days: 6% vs 10%, p<0.001, 365 days: 13% vs 20%, p<0.001). The average Finnish patient was first admitted to a hospital treating 540 ACS patients per year (average travel time by car: 40 min), increasing to 590 patients (travel time: 43 min) during the first episode including transfers to higher level hospitals. Corresponding numbers for Norway were 630 ACS patients per year for the first admission (travel time: 60 min) and 1240 patients (!) for the first episode (travel time: 96 min). In Finland, 48% of STEMI and 39% of non-STEMI, undefined and unstable angina patients were admitted to hospitals with an emergency PCI service during the episode. The corresponding numbers for Norway were 77% and 66%. However, more patients received PCI within 2 days in Finland than Norway (38% vs. 33%, p<0.001), and the distribution of PCIs performed during weekends was similar (23% vs. 23%, p=0.55). Both in Norway and Finland non-STEMI patients who not receive PCI have a significantly lower mortality if they are treated at hospital with PCI facility than at other hospitals (OR 0.65 in Norway and 0.73 in Finland for 365 days mortality, p<0.001). This may indicate better quality at high volume centers. Further work: Multilevel logistic models with individual level risk adjustment and hospital level variables and random effects are going to be used to study if the reduced preparedness for PCI at some of the Finnish hospitals and differences in organization of care for ACS patients add to our understanding of mortality differences between Finland and Norway.

• Swanson, Jayson O. J; Vogt, Verena; Sundmacher, Leonie; Hagen, Terje P. & Moger, Tron Anders (2017). Continuity of care and its effect on readmissions for COPD patients: A comparative study of Norway and Germany. Full text in Research Archive
• Tjerbo, Trond; Hagen, Terje P. & Monkerud, Lars Chr. (2017). Is there a health political budget cycle? An analysis of growth in health expenditure in election years for OECD countries. Full text in Research Archive
• Häkkinen, Unto; Hagen, Terje P. & Moger, Tron Anders (2017). Performance comparison of hip fracture pathways in two metropolitan areas - does the level of integration matter? Full text in Research Archive
• Moger, Tron Anders; Häkkinen, Unto & Hagen, Terje P. (2017). Higher mortality among ACS patients in Finland than in Norway: Do differences in acute services and scale effects in hospital treatment explain the variation? Full text in Research Archive
• Alexandersen, Nina; Hagen, Terje P. & Kaarbøe, Oddvar Martin (2016). Hvilke bedrifter kjøper private helseforsikringer i Norge? Full text in Research Archive
• Hagen, Terje P. & Iversen, Tor (2016). EuroHOPE – sammenligning av helseutfall og behandlingskostnader mellom sju europeiske land. BestPractice. p. 17–19. Full text in Research Archive
• Hagen, Terje P.; Tjerbo, Trond & Aarflot, Morten (2024). Brukerne blir yngre, psykiske lidelser øker: Dypdykk i pleie- og omsorgstjenestene 2017-2021. Helseøkonomisk forskningsprogram ved Universitetet i Oslo. Full text in Research Archive Show summary

  Det var en kraftig vekst i utgiftene i kommunenes pleie- og omsorgstjenester i perioden 2015-2020. Veksten flatet ut i 2020, men har i årene 2021 og 2022 igjen vært kraftig – nesten 9 prosent per år. Det er spesielt i tjenester til hjemmeboende veksten har vært sterk. I tillegg har veksten vært sterk i aldersgruppene under 80 år.Hovedmålsettingene med denne rapporten har vært å gå dypere i tre temaer: - Langtidsopphold i institusjoner: I en tidligere analyse (Andrews et al., 2021; Hagen & Tjerbo, 2023) fant vi at veksten i langtidsoppholdene kom i aldersgruppene under 80 år. Her stiller vi spørsmål om årsakene til denne endringen. Har de ‘yngre’ brukergruppene større behov enn de eldre? - Høykostnadsbrukere: I de tidligere analysene fant vi også indikasjoner på at en del yngre hjemmeboende brukere var kostnadskrevende. Her definerer vi høykostnadsbrukerne som de mottakere av pleie- og omsorgstjenester som har de 5% høyeste kostnadene og stiller følgende spørsmål: Hvor stor andel av de samlede pleie- og omsorgstjenestene kan knyttes til de 5 prosentene med høyest kostnader? Hva kjennetegner brukergruppen med høyest kostnader? - Samhandling mellom sykehus og kommuner: Hoftebruddspasientene er en særlig sårbar gruppe. Pasientene er gamle, skrøpelige og har mange tilleggssykdommer (komorbiditeter). Dødeligheten i gruppen er høy. Spørsmålene vi stiller er hvilke effekter reduksjon i sykehusenes liggetider, hardere konkurranse om sykehjemsplassene og bedre helse blant de eldre, til sammen har for pasientenes overlevelse. Klarer kommunene å kompensere for den reduserte liggetiden i sykehus?

• Tjerbo, Trond; Førland, Oddvar; Sørvoll, Jardar; Hagen, Terje P.; Fosse, Rina Moe & Ambugo, Eliva Atieno [Show all 8 contributors for this article] (2022). Resultatevaluering av Omsorg 2020 – regjeringens plan for omsorgsfeltet 2015–2020. Universitetet i Oslo. ISSN 9788277562735. Full text in Research Archive
• Andrews, Therese Marie; Tjerbo, Trond; Ambugo, Eliva Atieno; Bliksvær, Trond; Fabritius, Merete Kvamme & Aguinaldo, Sean Jayven [Show all 7 contributors for this article] (2021). Årsaker til kostnadsvekst i kommunale pleie- og omsorgstjenester. Nordlandsforskning. ISSN 9788273217615. Full text in Research Archive Show summary

  Studien som ligger til grunn for rapporten, belyser årsaker til kostnadsvekst i kommunale pleie- og omsorgstjenester basert på data fra KOSTRA (2015- 2019), Kommunalt pasientregister (2017-2020), og intervjuer med ledere i 15 kommuner. Rapporten viser hvilke tjenesteområder som har hatt størst vekst, og til hvilke typer brukere og hvilke aldersgrupper som veksten i tjenester har vært størst. Kvalitative data utdyper og nyanserer resultater fra det statistiske datamaterialet. I rapporten diskuteres også noen bakenforliggende forhold som har bidratt til å forklare veksten i utgifter til denne sektoren.

• Hagen, Terje P. & Kaarbøe, Oddvar Martin (2020). Har bedriftenes kjøp av private helseforsikringer effekter for sykefraværet? Universitetet. Full text in Research Archive
• Westberg, Nina Buvik; Skjeflo, Sofie Waage; Hveem, Ellen Balke; Pedersen, Simen; Øien, Henning & Sørvoll, Jardar [Show all 9 contributors for this article] (2019). Evaluering av investeringstilskudd til omsorgsboliger og sykehjem. Menon Economics. Full text in Research Archive
• Ambugo, Eliva; Hoel, Viktoria & Hagen, Terje P. (2018). [*Report]: “Sustainable tailored integrated care for older people in Europe (SUSTAIN-project): Lessons learned from improving integrated care in Norway.”. SUSTAIN consortium. Full text in Research Archive
• Häkkinen, Unto; Engel-Andreasen, Christopher; Hagen, Terje P.; Goude, Fanny; Moger, Tron Anders & Kruse, Marie [Show all 8 contributors for this article] (2018). Performance comparison of patient pathways in Nordic capital areas. A pilot study. THL. ISSN 9789523431348. Full text in Research Archive
• Kaarbøe, Oddvar Martin; Hagen, Terje P. & Aleksandersen, Nina (2016). Hvilke bedrifter kjøper private helseforsikringer i Norge? 7Letras. Full text in Research Archive
• Lappegard, Øystein; Hagen, Terje P. & Hjortdal, Per (2016). Acute admissions to a community hospital: a descriptive cost study. Institutt for helse og samfunn, Universitetet i Oslo. Full text in Research Archive
• Swanson, Jayson O. J; Hagen, Terje P. & Alexandersen, Nina (2016). Førte opprettelsen av kommunale akutte døgnenheter til færre innleggelser ved somatiske sykehus? HERO working paper 1/2016. Universitetet i Oslo. ISSN 9788277562513. Full text in Research Archive
• Ambugo, Eliva Atieno; Hagen, Terje P. & Vaage, Silje Kathrine Hofgaard (2016). [*Report]: “Current situation and the ambition of sites participating in the SUSTAIN project: Norway.” In P. Wosko & G. Ruppe (Eds.), Integrated care for older people living at home: Current situation and ambition of sites participating in the SUSTAIN project. Austrian Interdisciplinary Platform on Ageing / OEPIA. Full text in Research Archive

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