Helge Garåsen The Trondheim Model - NSDM

designed to assess the appropriateness of care in acute general care hospitals, studies have
shown a low level of validity when reviewed retrospectively by trained reviewers (150-152).
A major challenge, when defining indicators of the makeup of appropriate care, is to increase
measurability and objectivity while retaining validity and relevance. However; there are no
indicators in Norway on appropriate care, when a patient is classified ready for discharge
from general hospitals or when the patient needs general hospital care (excluding requisite
acute care as defined by law) (153). As a consequence the two expert panels had to rely on
their own clinical experiences and judgments.
To avoid possible bias by letting only one panel assessing all the letters, two panels were
recruited.
Another consequence of the study’s design was that the predictions also reflected the interpanel
variation of the assessments; including scrutiny of the agreement between the panels.
The agreement between the matching panels was satisfactory in the fields where there exist
common professional agreements on the definition of sufficient information (medical history,
medication) (Table 3). However, in fields where information about ADL and social network
was a necessity when assessing the level of need for care at home or in nursing homes, the
degree of agreement between the panels and the panellists was lower.
Table 3. Assessments of consensus between panels A and B on the quality of varying
elements in information in the referral letters (n=25).
Observed agreement Proportional agreement κ (95 % CI)
Low Intermediate High
Quality of
Medical history 0.96 1.00 0.50 0.96 0.78 (0.37-1.00)
Signs 0.52 0.09 0.00 0.52 0.10 (0.00-0.47)
Medication 1.00 1.00 1.00 1.00 1.00 (1.00-1.00)
ADL 0.58 0.25 0.18 0.58 0.25 (0.00-0.61)
Social network 0.44 0.67 0.33 0.13 0.14 (0.00-0.44)
Need of care 0.72 0.75 0.15 0.17 0.51 (0.20-0.82)
Benefit 0.79 0.00 0.40 0.77 0.35 (0.00-0.86)
Also the Bland-Altman diagram (145) showed small variations between the panels (Figure
2). On the topic of medication there were no differences between the panels for 21 persons, a
difference of one in three cases and two in one case. Regarding the benefits of general
hospital care, which was the element where disagreement between the panels was greatest,
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