To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care: a multilevel study

BACKGROUND

In the Netherlands, primary out-of-hours (OOH) care is provided by large scale General Practitioner (GP) cooperatives. GP cooperatives can be contacted by patients living in the area surrounding the GP cooperative (catchment area) at hours when the patient's own general practice is closed. The frequency of primary OOH care use substantially differs between GP cooperative catchment areas. To enable a better match between supply and demand of OOH services, understanding of the factors associated with primary OOH care use is essential. The present study evaluated the contribution of sociodemographic composition of the neighbourhood in explaining differences in primary OOH care use between GP cooperative catchment areas.

METHODS

Data about patients' contacts with primary OOH services (n = 1,668,047) were derived from routine electronic health records of 21 GP cooperatives participating in the NIVEL Primary Care Database in 2012. The study sample is representative for the Dutch population (for age and gender). Data were matched with sociodemographic characteristics (e.g. gender, age, low-income status, degree of urbanisation) on postcode level. Multilevel linear regression models included postcode level (first level), nested within GP cooperative catchment areas (second level). We investigated whether contacts in primary OOH care were associated with neighbourhood sociodemographic characteristics.

RESULTS

The demand of primary OOH care was significantly higher in neighbourhoods with more women, low-income households, non-Western immigrants, neighbourhoods with a higher degree of urbanisation, and low neighbourhood socioeconomic status. Conversely, lower demand was associated with neighbourhoods with more 5 to 24 year old inhabitants. Sociodemographic neighbourhood characteristics explained a large part of the variation between GP cooperatives (R-squared ranging from 8% to 52%). Nevertheless, the multilevel models also showed that a considerable amount of variation in demand between GP cooperatives remained unexplained by sociodemographic characteristics, particularly regarding high-urgency contacts.

CONCLUSIONS

Although part of the variation between GP cooperatives could not be attributed to neighbourhood characteristics, the sociodemographic composition of the neighbourhood is a fair predictor of the demand of primary OOH care. Accordingly, this study provides a useful starting point for an improved planning of the supply of primary OOH care.

Residents' and attendings' perceptions of a night float system in an internal medicine program in Canada

BACKGROUND

The Night Float system (NFS) is often used in residency training programs to meet work hour regulations. The purpose of this study was to examine resident and attendings' perceptions of the NFS on issues of resident learning, well-being, work, non-educational activities and the health care system (patient safety and quality of care, inter-professional teams, workload on attendings and costs of on-call coverage).

METHODS

A survey questionnaire with closed and open-ended questions (26 residents and eight attendings in an Internal Medicine program), informal discussions with the program and moonlighting and financial data were collected.

RESULTS AND DISCUSSION

The main findings included, (i) an overall congruency in opinions between resident and attendings across all mean comparisons, (ii) perceptions of improvement for most aspects of resident well-being (e.g. stress, fatigue) and work environment (e.g. supervision, support), (iii) a neutral effect on the resident learning environment, except resident opinions on an increase in opportunities for learning, (iv) perceptions of improved patient safety and quality of care despite worsened continuity of care, and (v) no increases in work-load on attendings or the health care system (cost-neutral call coverage). Patient safety, handovers and increased utilization of moonlighting opportunities need further exploration.

Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey

OBJECTIVE

To investigate the experience of users of out of hours general practitioner services in England, UK.

DESIGN

Population based cross sectional postal questionnaire survey.

SETTING

General Practice Patient Survey 2012-13.

MAIN OUTCOME MEASURES

Potential associations between sociodemographic factors (including ethnicity and ability to take time away from work during working hours to attend a healthcare consultation) and provider organisation type (not for profit, NHS, or commercial) and service users' experience of out of hours care (timeliness, confidence and trust in the out of hours clinician, and overall experience of the service), rated on a scale of 0-100. Which sociodemographic/provider characteristics were associated with service users' experience, the extent to which any observed differences could be because of clustering of service users of a particular sociodemographic group within poorer scoring providers, and the extent to which observed differences in experience varied across types of provider.

RESULTS

The overall response rate was 35%; 971,232/2,750,000 patients returned surveys. Data from 902,170 individual service users were mapped through their registered practice to one of 86 providers of out of hours GP care with known organisation type. Commercial providers of out of hours GP care were associated with poorer reports of overall experience of care, with a mean difference of -3.13 (95% confidence interval -4.96 to -1.30) compared with not for profit providers. Asian service users reported lower scores for all three experience outcomes than white service users (mean difference for overall experience of care -3.62, -4.36 to -2.89), as did service users who were unable to take time away from work compared with service users who did not work (mean difference for overall experience of care -4.73, -5.29 to -4.17).

CONCLUSIONS

Commercial providers of out of hours GP care were associated with poorer experience of care. Targeted interventions aimed at improving experience for patients from ethnic minorities and patients who are unable to take time away from work might be warranted.

Strategies for improving education on night-float rotations: a review

INTRODUCTION

Night float rotations (NF) have been developed as a means of achieving duty hour compliance among residency programs. These were initially pioneered in the late 1980s as a response to fatigue among residents. The NF experience had its genesis in work hour reform and providing hospital service moreso than education. However, as NF has become ubiquitous, it is not clear that we have adequately revisited the educational component of this experience. We systematically reviewed the literature on educational aspects of a night float experience.

METHODS

PubMed searches were conducted for the terms "night float" and "night, curriculum, residency." This yielded 320 articles. Concerning educational aspects of the NF reduced the total to 134 articles. Editorials and those concerning procedural volumes or handoffs were also excluded. Most articles used surveys as methodology, so formal statistical analysis was not possible.

RESULTS

In total, 42 independent articles were found that directly related to the educational value of NF rotations, spanning all of the medical disciplines. Each study was searched for interventions or strategies that may affect the educational value of the NF experience. These may be grouped broadly into 3 discrete categories: (1) attention to the sleep-wake cycle, (2) addition of personal to augment the experience and (3) incorporation of formal educational elements to night rotations. A summary of these strategies is presented in Table 3.

CONCLUSIONS

NF is a practical solution to the challenge of work hour restrictions in residency, and is likely to persist in the future. Some educational issues arise due to the altered physiology of a reversed sleep-wake cycle, which may be best resolved through structural limitations of the night rotations. Other deficiencies are based on lack of interactions, for which there are strategies to improving the NF educational experience.

"Same as it ever was"--only different: a successful ACGME innovative project to equip PGY I residents to take at-home call

OBJECTIVE

Establish a competency-based system for advancement of postgraduate year (PGY) I residents to take at-home call, with indirect and direct supervision available.

DESIGN

Application of an innovative project approved by the ACGME to equip PGY I residents to take at-home call was successful. Formal education of PGY I residents with a variety of modalities included the successful completion of the Fundamentals of Surgery Curriculum and a structured 12-week curriculum, which focused on medical knowledge, patient care, systems-based practice, and skills lab scenarios. Residents were responsible for inpatient care during the day with direct supervision. Patient care logs (PCLs) were maintained by the resident for patient encounters. The PGY I residents were evaluated with faculty and senior resident review of the PCLs, a written examination, nurse mock pages, and oral proficiency examinations. The decision to permit the resident to take at-home call was determined by the Clinical Competency Committee (CCC).

SETTING

Independent academic medical center with 3 categorical surgical residents per year.

PARTICIPANTS

Categorical PGY I surgery residents from 2013 to 2014.

RESULTS

Residents completed the structured program and successfully passed the oral and written examinations. The CCC determined that the residents were able to take at-home call starting in October of the PGY I year. The number and type of patients were monitored with specified limitations and ongoing maintenance and review of PCLs. A formal backup system, with senior resident and faculty availability by phone or physical presence, was used.

CONCLUSION

We present an Accreditation Council for Graduate Medical Education-approved innovative project, which appears to have been successful in implementing at-home call for PGY I residents. This enables the progressive development of PGY I residents and assists our CCC in the development of competency-based milestones for advancement. The effect of this project is significant for those residency programs where incorporation of at-home call is possible.

[Walk in clinics and out-of-hours care: 10 years later]

The provision of care in general practice has changed significantly over recent years due to changes in the lifestyles of both doctors and patients. Moreover, the "inappropriate" use of emergency services is a critical issue which requires urgent attention. We conducted a review of both the Belgian and international literature to examine how frontline care has adapted and what issues these developments raise. In many countries, specific structures, such as walk-in clinics, out-of-hours centers, the deputizing services, have emerged creating a professional system of frontline care delivery. In Belgium, the Health and Disability Insurance system delegates the organization of out-of-hours primary care to local general practice assemblies who can develop services according to local requirements. In effect, new service delivery systems draw from a variety of models implemented in countries such as Canada, the United States or The Netherlands.

Foundation doctors working at night: what training opportunities exist?

INTRODUCTION

Foundation Training is designed for doctors in their first two years of post-graduation. The number of foundation doctors (FD) in the UK working nights has reduced because of a perception that clinical supervision at night is unsatisfactory and that minimal training opportunities exist. We aimed to assess the value of night shifts to FDs and hypothesised that removing FDs from nights may be detrimental to training.

METHODS

Using a survey, we assessed the number of FDs working nights in London, FDs views on working nights and their supervision at night. We evaluated whether working at night, compared to daytime working provided opportunities to achieve foundation competencies.

RESULTS

83% (N = 2157/2593) of FDs completed the survey. Over 90% of FDs who worked nights felt that the experience they gained improved their ability to prioritise, make decisions and plan. FDs who worked nights reported higher scores for achieving competencies in history taking (2.67 vs. 2.51; p = 0.00), examination (2.72 vs. 2.59; p = 0.01) and resuscitation (2.27 vs. 1.96; p = 0.00). The majority (65%) felt adequately supervised.

CONCLUSIONS

Our survey has demonstrated that FDs find working nights a valuable experience, providing important training opportunities, which are additional to those encountered during daytime working.

The Danish Fracture Database can monitor quality of fracture-related surgery, surgeons' experience level and extent of supervision

INTRODUCTION

The importance of supervision and of surgeons' level of experience in relation to patient outcome have been demonstrated in both hip fracture and arthroplasty surgery. The aim of this study was to describe the surgeons' experience level and the extent of supervision for: 1) fracture-related surgery in general; 2) the three most frequent primary operations and reoperations; and 3) primary operations during and outside regular working hours.

MATERIAL AND METHODS

A total of 9,767 surgical procedures were identified from the Danish Fracture Database (DFDB). Procedures were grouped based on the surgeons' level of experience, extent of supervision, type (primary, planned secondary or reoperation), classification (AO Müller), and whether they were performed during or outside regular hours.

RESULTS

Interns and junior residents combined performed 46% of all procedures. A total of 90% of surgeries by interns were performed under supervision, whereas 32% of operations by junior residents were unsupervised. Supervision was absent in 14-16% and 22-33% of the three most frequent primary procedures and reoperations when performed by interns and junior residents, respectively. The proportion of unsupervised procedures by junior residents grew from 30% during to 40% (p < 0.001) outside regular hours.

CONCLUSION

Interns and junior residents together performed almost half of all fracture-related surgery. The extent of supervision was generally high; however, a third of the primary procedures performed by junior residents were unsupervised. The extent of unsupervised surgery performed by junior residents was significantly higher outside regular hours.

FUNDING

not relevant.

TRIAL REGISTRATION

The Danish Fracture Database ("Dansk Frakturdatabase") was approved by the Danish Data Protection Agency ID: 01321.

Can mobile technology improve response times of junior doctors to urgent out-of-hours calls? A prospective observational study

BACKGROUND

The Hospital at Night system has been widely adopted to manage Out-of-Hours workload. However, it has the potential to introduce delays and corruption of information. The introduction of newer technologies to replace landlines, pagers and paper may ameliorate these issues.

AIM

To establish if the introduction of a Hospital at Night system supported by a wireless taskflow system affected the escalation of high Early Warning Scores (EWSs) to medical attention, and the time taken to medical review.

DESIGN

Prospective 'pre and post' observational study in a teaching hospital in the UK.

METHODS

Review of observation charts and medical records, and data extraction from the electronic taskflow system.

RESULTS

The implementation of a technology-supported Hospital at Night system was associated with a significant decrease in time to documentation of initial review in those who were reviewed. However, there was no change in the proportion of those with a high EWS that were reviewed, and throughout the study a majority of patients with high EWSs were not reviewed in accordance with guidelines.

CONCLUSION

Introduction of a Hospital at Night system supported by mobile technology appeared to improve the transfer of information, but did not affect the nursing decision whether to escalate abnormal findings.