Should I stay or should I go – Factors associated with hospitalization risk among older persons in Sweden

An increasingly older population will most likely lead to greater demands on the health care system, as older age is associated with an increased risk of having acute and chronic conditions. The number of diseases or disabilities is not the only marker of the amount of health care utilized, as persons may seek hospitalization without a disease and/or illness that requires hospital healthcare. Hospitalization may pose a severe risk to older persons, as exposure to the hospital environment may lead to increased risks of iatrogenic disorders, confusion, falls and nosocomial infections, i.e., disorders that may involve unnecessary suffering and lead to serious consequences. Aims: The overall aim of this thesis was to describe and explore individual trajectories of cognitive development in relation to hospitalization and risk factors for hospitalization among older persons living in different accommodations in Sweden and to explore older persons' reasons for being transferred to a hospital. Methods: The study designs were longitudinal, prospective and descriptive, and both quantitative and qualitative methods were used. Specifically, latent growth curve modelling was used to assess the association of cognitive development with hospitalization. The Cox proportional hazards regression model was used to analyse factors associated with hospitalization risk overtime. In addition, an explorative descriptive design was used to explore how home health care patients experienced and perceived their decision to seek hospital care. Results: The most common reasons for hospitalization were cardiovascular diseases, which caused more than one-quarter of first hospitalizations among the persons living in ordinary housing and nursing home residents (NHRs). The persons who had been hospitalized had a lower mean level of cognitive performance in general cognition, verbal, spatial/fluid, memory and processing speed abilities compared to those who had not been hospitalized. Significantly steeper declines in general cognition, spatial/fluid and processing speed abilities were observed among the persons who had been hospitalized. Cox proportional hazards regression analysis showed that the number of diseases, number of drugs used, having experienced a fall and being assessed as malnourished according to the Mini Nutritional Assessment scale were related to an increased hospitalization risk among the NHRs. Among the older persons living in ordinary housing, the risk factors for hospitalization were related to marital status, i.e., unmarried persons and widows/widowers had a decreased hospitalization risk. In addition, among social factors, receipt of support from relatives was related to an increased hospitalization risk, while receipt of support from friends was related to a decreased risk. The number of illnesses was not associated with the hospitalization risk for older persons in any age group or for those of either sex, when controlling for other variables. The older persons who received home health care described different reasons for their decisions to seek hospital care. The underlying theme of the home health care patients’ perceptions of their transfer to a hospital involved trust in hospitals. This trust was shared by the home health care patients, their relatives and the home health care staff, according to the patients. Conclusions: This thesis revealed that middle-aged and older persons who had been hospitalized exhibited a steeper decline in cognition. Specifically, spatial/fluid, processing speed, and general cognitive abilities were affected. The steeper decline in cognition among those who had been hospitalized remained even after controlling for comorbidities. The most common causes of hospitalization among the older persons living in ordinary housing and in nursing homes were cardiovascular diseases, tumours and falls. Not only health-related factors, such as the number of diseases, number of drugs used, and being assessed as malnourished, but also social factors and marital status were related to the hospitalization risk among the older persons living in ordinary housing and in nursing homes. Some risk factors associated with hospitalization differed not only between the men and women but also among the different age groups. The information provided in this thesis could be applied in care settings by professionals who interact with older persons before they decide to seek hospital care. To meet the needs of an older population, health care systems need to offer the proper health care at the most appropriate level, and they need to increase integration and coordination among health care delivered by different care services.

Examining Levels of Automation in the Wood Processing Industry - A case study

Companies operating in the wood processing industry need to increase their productivity by implementing automation technologies in their production systems. An increasing global competition and rising raw material prizes challenge their competitiveness. Yet, too extensive automation brings risks such as a deterioration in situation awareness and operator deskilling. The concept of Levels of Automation is generally seen as means to achieve a balanced task allocation between the operators’ skills and competences and the need for automation technology relieving the humans from repetitive or hazardous work activities. The aim of this thesis was to examine to what extent existing methods for assessing Levels of Automation in production processes are applicable in the wood processing industry when focusing on an improved competitiveness of production systems. This was done by answering the following research questions (RQ): RQ1: What method is most appropriate to be applied with measuring Levels of Automation in the wood processing industry? RQ2: How can the measurement of Levels of Automation contribute to an improved competitiveness of the wood processing industry’s production processes? Literature reviews were used to identify the main characteristics of the wood processing industry affecting its automation potential and appropriate assessment methods for Levels of Automation in order to answer RQ1. When selecting the most suitable method, factors like the relevance to the target industry, application complexity or operational level the method is penetrating were important. The DYNAMO++ method, which covers both a rather quantitative technical-physical and a more qualitative social-cognitive dimension, was seen as most appropriate when taking into account these factors. To answer RQ 2, a case study was undertaken at a major Swedish manufacturer of interior wood products to point out paths how the measurement of Levels of Automation contributes to an improved competitiveness of the wood processing industry. The focus was on the task level on shop floor and concrete improvement suggestions were elaborated after applying the measurement method for Levels of Automation. Main aspects considered for generalization were enhancements regarding ergonomics in process design and cognitive support tools for shop-floor personnel through task standardization. Furthermore, difficulties regarding the automation of grading and sorting processes due to the heterogeneous material properties of wood argue for a suitable arrangement of human intervention options in terms of work task allocation.  The application of a modified version of DYNAMO++ reveals its pros and cons during a case study which covers a high operator involvement in the improvement process and the distinct predisposition of DYNAMO++ to be applied in an assembly system.