Marion Haugen

Introduction Global Trigger Tool (GTT) is a retrospective review method where inpatient medical records are randomly sampled and reviewed by trained GTT teams to identify and monitor adverse event (AE) rates over time. Tracking AEs over time is a useful way to indicate if targeted changes result in improved patient safety. The method presupposes that the teams are consistent in their record reviews. The objective of our study was to examine several teams’ ability to reproduce their findings from a previous review. There is no consensus in the GTT literature regarding this reproducibility. Methods Eight teams from six Norwegian hospitals applied the GTT method to a total of 958 randomly selected inpatient medical records. Each inpatient record was previously reviewed in 2016-2018 and then reexamined in 2023. We estimated the teams’ agreement between the previous and new ratings, with focus on the teams’ reproducibility for rating the presence of at least one AE or not. The teams’ ratings of the number of AEs and the AE severity level were also considered. We computed and compared several well-known agreement measures. The study was approved by Regional Committees for Medical and Health Research Ethics in Norway. The participating hospitals’ Data Protection Officers have given their approval. Results Overall there was good to very good agreement between the teams’ previous and new ratings for the presence of at least one AE or not. The unadjusted agreement for all teams together was 84.9%, and on team level it ranged between 76.7% and 89.2%. The agreement for all teams together, adjusted for agreement by chance, ranged from Fleiss’ κ: 0.673 (0.625 – 0.722) to Gwet’s AC1: 0.718 (0.674 – 0.762). At team level, we found some differences in the reproducibility of the presence of at least one AE or not. The ability to reproduce previous findings on the number of AEs and AE severity level varied more across teams. Conclusion Our findings support the use of the GTT method as a tool for identifying and monitoring AE rates over time, with the aim of reducing patient harm. It appears to be more challenging to obtain good consistency when rating the number of AEs and AE severity level than the presence of at least one AE or not. We believe there is a need for better training and auxiliary resources for the teams if the goal is to improve the reproducibility of the number of AEs and AE severity level.

Statistisk sentralbyrå (SSB) publiserer månedlig statistikk over utenrikshandel med varer (UHV). Formålet med statistikken er å gi en oversikt over varestrømmene mellom Norge og utlandet. Eksport og import av varer er sentrale størrelser i det samfunnsøkonomiske bildet, og følgelig er det viktig at statistikken som publiseres er presis. Norsk Regnesentral (NR) har analysert tolldata på import av varer fra TollVesenets INformasjonssystem med Næringslivet (TVINN). Alle importerte varer registreres gjennom en varelinje, med et varenummer som beskriver varetypen fra Tolltariffen, og feil varenummer er en vanlig feiltype. I en del tilfeller innebærer en slik feilregistrering manglende samsvar mellom varenummer og varebeskrivelsen. I dette prosjektet har vi brukt en språkmodell til å innkode varebeskrivelsen, et fritekstfelt, for så å predikere varenummeret til en varelinje ved hjelp av logistisk regresjon. I tillegg har vi eksperimentert med å bruke gradientforsterkede tremodeller til samme formål, basert på andre felt fra hver varelinje. Disse modellene er trent på varelinjer fra enten 2017 - 2021, eller 2020 - 2023, som er kontrollert og har fått varenummeret sitt korrigert. Ved å teste modellene på uavhengige testdata fra 2024, finner vi at modellene tilpasset varebeskrivelsene oppnår en rimelig høy treffsikkerhet, med en treffsikkerhet på ca. 65% for tekstmodellen tilpasset varelinjer fra perioden 2020 - 2023, evaluert på litt over 24 tusen korrigerte varelinjer. De gradientforsterkede tremodellene har ikke oppnådd tilsvarende ytelse, med en maksimal treffsikkerhet på ca. 11%, antageligvis delvis grunnet overtilpasning til treningsdataene.

Introduction: All Norwegian hospital trusts have measured adverse event rates since 2011 using the Global Trigger Tool (GTT). As they have different GTT teams, results have not been compared between them and interrater reliability has not been established. All Norwegian GTT teams undergo the same national training, which prompted an interest in exploring the feasibility of comparing results between hospital trusts. Objective: To organize a research project testing interrater reliability between 20 GTT teams in 13 hospital trusts and one hospital. Methods: Sending medical records securely between hospital trusts was a difficult challenge. Due to privacy regulations, accessing electronic medical records across hospital trusts was not possible. The research project limited the inclusion of data from the medical records to no more than 30 days prior to and after hospital admission. This made the medical record extraction more time consuming. Two hospital trusts used a robot for extracting medical records. The Regional committee for medical and health research ethics (REK) consented to the research project. Results: Digital mail for public enterprises (DPE) was recently developed in Norway to send and receive electronic post securely. This became the solution for distributing the medical records, and required that several of the hospital trusts had to implement the DPE solution. 920 medical records were converted to PDFs by and distributed from 14 GTT teams, to between one and four other GTT teams involved in the project. The National Archives of Norway approved the required records retention and disposal plan, which detailed the disposal of all PDF versions of the medical records throughout the workflow. Conclusion: The logistical challenges and solutions associated with securely sending 920 medical records between different hospital trusts nationwide, makes the experiences from this research project relevant for other national settings that might wish to take a similar approach.

Objectives In this paper, we explore and compare types and longitudinal trends of hospital adverse events in Norway and Sweden in the years 2013–2018 with special reference to AEs that contributed to death. Design Acute care hospitals in both countries performed medical record reviews on randomly selected medical records from all eligible admissions. Analysis: Comparison between Norway and Sweden of linear trends from 2013–2018, and percentage rates of admissions with at least one AE according to types and severities. Setting Norway and Sweden have similar socio-economic and demographic characteristics, which constitutes a relevant context for cooperation, comparison and mutual learning. This setting has promoted the use of GTT to monitor national rates of AEs in hospital care in the two countries. Participants 53 367 medical records in Norway and 88 637 medical records in Sweden were reviewed. Results 13.2% of hospital admissions in Norway and 13.1% in Sweden were associated with an AE of all severities (E-I). 0.23% of hospital admissions in Norway and 0.26% in Sweden were associated with an AE that contributed to death (I). The differences between the two countries were not statistically significant. Conclusions There were no significant differences in overall rates (E-I) of AEs in Norway and Sweden, nor in rates of AEs that contributed to death (I). There was no significant change in AEs or fatal AEs in either country over the six-year time period.

Reliable projections of extremes by climate models are becoming increasingly important in the context of climate change and associated societal impacts. Extremes are by definition rare events, characterized by a small sample associated with large uncertainties. The evaluation of extreme events in model simulations thus requires performance measures that compare full distributions rather than simple summaries. This paper proposes the use of the integrated quadratic distance (IQD) for this purpose. The IQD is applied to evaluate CMIP5 and CMIP6 simulations of monthly maximum and minimum near-surface air temperature over Europe and North America against both observation-based data and reanalyses. Several climate models perform well to the extent that these models' performance is competitive with the performance of another data product in simulating the evaluation set. While the model rankings vary with region, season and index, the model evaluation is robust against changes in the grid resolution considered in the analysis. When the model simulations are ranked based on their similarity with the ERA5 reanalysis, more CMIP6 than CMIP5 models appear at the top of the ranking. When evaluated against the HadEX2 data product, the overall performance of the two model ensembles is similar.

Global circulation models (GCMs) are used for projecting climate changes on a global scale. However, when we need information for local climate changes, a dynamical downscaling through a regional climate model (RCM) may be used to gain more precise information. Therefore it is important to make good RCMs that are unbiased when projecting climate changes. This note investigates the skill of precipitation projections from five combinations of global and regional climate models from EURO-CORDEX and four bias correction methods applied to some of these. This is performed by comparing the model outputs with data from the E-OBS and NGCD data products using integrated quadratic distance.

BACKGROUND: For children with disputed date of birth, age assessments based on skeletal and dental development are recommended. AIM: The aim of this retrospective study was to compare and contrast the results of age assessments from these two methods performed on unaccompanied asylum seeking children in Norway. In addition the aim of the analysis was to see if the skeletal age assessment from hand-wrist was operator sensitive. MATERIALS AND METHODS: Age assessments performed from January 2010 to December 2014 were analysed. Skeletal development of hand-wrist was graded according to Greulich and Pyle (1959). Dental development of the wisdom teeth was scored on orthopantomograms according to Moorrees, Fanning and Hunt (1963) and age assessed from tables published by Liversidge (2008) and Haavikko (1970). In the statistical analysis agreement between the two age assessments was defined according to the asylum seeker's age being assessed to be older or younger than 18 years. The statistical analysis included 3333 boys and 486 girls. RESULTS: The agreement was 83% for boys and 79% for girls. Approximately 70% of the boys and girls were 18 years or older by both methods. It was more common that the skeletal age was assessed older than 18 years and dental age younger than 18 years for both genders. It could be demonstrated that the age assessment based on skeletal maturation was not operator sensitive. CONCLUSION: The analyses demonstrate that there is good agreement between the two age assessments, but a method to combine the results would increase the reliability of the age assessments.

This note investigates the fit of daily temperature projections over Fennoscandia for 1950- 2005 for nine combinations of global and regional climate models from EURO-CORDEX. The evaluation is performed by comparing temperature anomalies from the climate models to observed temperature anomalies from the E-OBS dataset using integrated quadratic distance (IQD). Summer and winter are evaluated separately. Different alternatives for a reference period are explored; 30-year periods, 20-year periods and 10-year periods. The evaluation results are robust for the 30-year periods, in both seasons. When the length of the reference period decreases, the evaluation results become less and less robust. It is hard to say if 20 years are sufficient so it is better to use 30 years. A reference period of 10 years is too short because the evaluation results highly depend on the chosen period.

Global climate models are used for projecting climate changes on a global scale. However, when we need information for local climate changes, a regional climate model with a finer grid that uses the global climate model as boundary conditions is necessary to gain more precise information. Therefore it is important to make good regional climate models that are unbiased when projecting climate changes. This note investigates the fit of precipitation projections from nine combinations of global and regional climate models from EURO-CORDEX and four bias correction methods applied to some of these. This is performed by comparing the models with data from the E-OBS dataset using integrated quadratic distance (IQD). All the climate models had difficulties with their projections in the areas of Fennoscandia with high amount of daily precipitation or long drought periods, while the IQD was improved for all climate models after bias correction, the IQD was still highest in the areas with more extreme data after bias correction. The LSCE-IPSL-CDFt-EOBS10-1971-2005 bias correction method obtained the best results for all our tests. However, this method was calibrated using the E-OBS dataset. As the other bias correction methods used different datasets the current results should be compared to an evaluation using alternative observation-based datasets.

Objectives: In this paper, we explore similarities and differences in hospital adverse event (AE) rates between Norway and Sweden by reviewing medical records with the Global Trigger Tool (GTT). Design: All acute care hospitals in both countries performed medical record reviews, except one in Norway. Records were randomly selected from all eligible admissions in 2013. Eligible admissions were patients 18 years of age or older, undergoing care with an in-hospital stay of at least 24 hours, excluding psychiatric and care and rehabilitation. Reviews were done according to GTT methodology. Setting: Similar contexts for healthcare and similar socioeconomic and demographic characteristics have inspired the Nordic countries to exchange experiences from measuring and monitoring quality and patient safety in healthcare. The co-operation has promoted the use of GTT to monitor national and local rates of AEs in hospital care. Participants: 10 986 medical records were reviewed in Norway and 19 141 medical records in Sweden. Results: No significant difference between overall AE rates was found between the two countries. The rate was 13.0% (95% CI 11.7% to 14.3%) in Norway and 14.4% (95% CI 12.6% to 16.3%) in Sweden. There were significantly higher AE rates of surgical complications in Norwegian hospitals compared with Swedish hospitals. Swedish hospitals had significantly higher rates of pressure ulcers, falls and ‘other’ AEs. Among more severe AEs, Norwegian hospitals had significantly higher rates of surgical complications than Swedish hospitals. Swedish hospitals had significantly higher rates of postpartum AEs. Conclusions: The level of patient safety in acute care hospitals, as assessed by GTT, was essentially the same in both countries. The differences between the countries in the rates of several types of AEs provide new incentives for Norwegian and Swedish governing bodies to address patient safety issues.

I Norge benyttes metoder for aldersvurdering dersom enslige mindreårige asylsøkere ikke kjenner til egen alder, eller har manglende eller usikre ID-papirer. Den medisinske aldersvurderingen består av to deler; en tannundersøkelse, som inkluderer et stort røntgenbilde av tenner, tannrøtter og kjever (OPG) for å undersøke tannutvikling, og en røntgenundersøkelse av hånd og håndrot der benveksten undersøkes. Resultatene av disse to uavhengige undersøkelsene sammenstilles til en endelig medisinsk aldersvurdering. Det har blitt observert en endring over tid i forholdet mellom aldersvurderinger basert på skjelettmodning og aldersvurderinger basert på tannutvikling. Da skjelettvurderingen ble utført av Barneradiologisk avdeling på Ullevål universitetssykehus fikk asylsøkerne oftere høyere skjelettalder enn tannalder. Etter at Unilabs Norge har overtatt skjelettvurderingen får mange asylsøkere lavere skjelettalder enn tannalder. I dette notatet sjekkes det om det er reelle forskjeller på disse to uavhengige aldersvurderingene. Vi mener at det i begge dataperioder er godt samsvar mellom aldersvurderinger basert på skjelettmodning og aldersvurderinger basert på tannutvikling utført på gutter og jenter i Norge fra 2010 til 2014, i henhold til om asylsøkers alder vurderes til å være over eller under 18 år. Ulik aldersfordeling og ulik fordeling av opprinnelsesland kan være med å forklare et skifte i forholdet mellom de to aldersvurderingene for gutter. Det er ingen endring over tid i forholdet mellom de to aldersvurderingene for jenter.

This final report describes the results of the research conducted in the project «Development of improved methods or basis for medical age assessments of minors and young adults». The aim of the project has been to contribute to develop improved methods for measuring physical developments of a child or young adult and for assessing the chronological age based on such measurements, giving an improved basis for such assessments. The project has brought together various international experts, both from the medical and odontology fields. The project has been an international collaboration with a group of partners with experience from both practical age estimation and research, from both of the currently used radiographic methods in Norway (wrist and teeth) and new MRI approaches. Several disciplines have been incorporated in the project: odontology, pediatrics, radiography, statistical modeling and image analysis. Additional descriptions of methods and results from the statistical analyses and image analysis can be found in four additional notes. The project is funded by The Norwegian Directorate of Immigration.

I Norge benyttes en medisinsk aldersvurdering dersom det ikke er mulig å fastsette med rimelig sikkerhet hvor gammel en enslig mindreårig asylsøker er. En røntgenundersøkelse av hånd og håndrot, der benveksten undersøkes manuelt, er den ene av to deler av en medisinsk aldersvurdering. Den visuelle analysen utføres av en radiolog ved at røntgenbildet som skal analyseres blir manuelt sammenlignet med bildeatlaset til Greulich og Pyle for å finne referansen som ligner mest, og ut i fra det bestemme skjelettalder. BoneXpert er programvare for automatisert estimering av skjelettalder fra røntgenbilder. Programvaren baserer seg på bildeanalyse av røntgenbilder av hånd og håndrot. Hensikten med automatisering er å gjøre skjelettvurderingen mer objektiv og mindre avhengig av radiologene som utfører de visuelle analysene. I dette notatet har vi testet BoneXpert på 100 utvalgte røntgenbilder av gutter som det tidligere har blitt utført en manuell skjelettvurdering på. Vi har sammenlignet skjelettalder fra manuell og automatisert skjelettvurdering. Testen viser at det er over 90% samsvar mellom manuell og automatisert skjelettvurdering, i henhold til om skjelettalder er over eller under 18 år. Det gode samsvaret skyldes at den manuelle skjelettvurderingen er presist utført, at BoneXpert er presis og gir en pålitelig skjelettvurdering, og at det er god kvalitet på de analyserte røntgenbildene.

Corporate customers often hold multiple contracts and this might give dependence between the lapsing times of the single policies. We present a shared gamma frailty model in order to study the time-to-lapse of single car policies for customers holding multiple car contracts with the same insurance company, accounting for measured and time-dependent covariates. Customers with the highest frailty value tend to leave the company earlier than the others and finding these is a central aspect within a company’s customer relationship management strategy.We estimate conditional survival curves which illustrate the decreased survival probability of a customer after a lapse in a single car insurance policy. The individual survival curves are overestimated if the underlying association for cars with the same customer is ignored. Fitting misspecified Cox’s proportional hazards model also results in an underestimation of the standard error of the parameter estimates.

Objectives To describe how adverse event (AE) rates were monitored and estimated nationally across all Norwegian hospitals from 2010 to 2013, and how they developed during the monitoring period. Monitoring was based on medical record review with Global Trigger Tool (GTT). Setting All publicly and privately owned hospitals were mandated to review randomly selected medical records to monitor AE rates. The initiative was part of the Norwegian patient safety campaign, launched by the Norwegian Ministry of Health and Care Services. It started in January 2011 and lasted until December 2013. 2010 was the baseline for the review. One of the main aims of the campaign was to reduce patient harm. Method To standardise the medical record reviews in all hospitals, GTT was chosen as a standard method. GTT teams from all hospitals reviewed 40 851 medical records randomly selected from 2 249 957 discharges from 2010 to 2013. Data were plotted in time series for local measurement and national AE rates were estimated, plotted and monitored. Results AE rates were estimated and published nationally from 2010 to 2013. Estimated AE rates in severity categories E-I decreased significantly from 16.1% in 2011 to 13.0% in 2013 (−3.1% (95% CI −5.2% to −1.1%)). Conclusions Monitoring estimated AE rates emerges as a potential element in national systems for patient safety. Estimated AE rates in the category of least severity decreased significantly during the first 2 years of the monitoring.

When two different methods of measuring some quantity are compared, the aim is to find out whether the methods agree well enough for one method to support or replace the other. The product-moment correlation coefficient is often used but this approach is misleading. The correlation coefficient measures association and not agreement. In this paper the limits of agreement approach, also known as the Bland Altman method, is applied to assess the agreement between age estimates from radiographs of the wrist and the teeth.

The aim of this paper is twofold. The first is to give an overview over the current state of the art and research challenges in the age estimation in youths and young adults. This implies a summary of the methods used for age estimation. The second is to give some national and European research programs and funding opportunities, and some international organizations in relation to the field of age estimation.