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Vinjerui KH, Asheim A, Sarheim Anthun K, Carlsen F, Mjølstad BP, Nilsen SM, Pape K, Bjørngaard JH. General practitioners retiring or relocating and its association with healthcare use and mortality: a cohort study using Norwegian national data. BMJ Qual Saf 2024:bmjqs-2023-017064. [PMID: 39060027 DOI: 10.1136/bmjqs-2023-017064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/26/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Continuity in the general practitioner (GP)-patient relationship is associated with better healthcare outcomes. However, few studies have examined the impact of permanent discontinuities on all listed patients when a GP retires or relocates. AIM To investigate changes in the Norwegian population's overall healthcare use and mortality after discontinuity due to Regular GPs retiring or relocating. METHODS Linking national registers, we compared days with healthcare use and mortality for matched individuals affiliated with Regular GPs who retired or relocated versus continued. We included list patients 3 years prior to exposure and followed them up to 5 years after. We assessed changes over time employing a difference-in-differences design with Poisson regression. RESULTS From 2011 to 2020, we identified 819 Regular GPs retiring and 228 moving, affiliated with 1 165 295 people. Relative to 3 years before discontinuity, the rate ratio (RR) of daytime GP contacts, increased 3% (95% CI 2 to 4) in year 1 after discontinuity, corresponding to 148 (95% CI 54 to 243) additional contacts per 1000 patients. This increase persisted for 5 years. Out-of-hours GP contacts increased the first year, RR 1.04 (95% CI 0.99 to 1.09), corresponding to 16 (95% CI -5 to 37) contacts per 1000 patients. Planned hospital contacts increased 3% (95% CI 2 to 4) in year 1, persisting into year 5. Acute hospital contacts increased 5% (95% CI 3 to 7), primarily in the first year. These 1-year effects corresponded to 51 (95% CI 18 to 83) planned and 13 (95% CI 7 to 18) acute hospital contacts per 1000 patients. Mortality was unchanged up to 5 years after discontinuity. CONCLUSION Regular GPs retirement and relocation were associated with small to moderate increases in healthcare use among listed patients, while mortality was unaffected.
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Affiliation(s)
- Kristin Hestmann Vinjerui
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Andreas Asheim
- Center for Health Care Improvement, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Mathematical Sciences, Faculty of Information Technology and Electrical Engineering, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Fredrik Carlsen
- Department of Economics, Faculty of Economics and Management, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Bente Prytz Mjølstad
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Sara Marie Nilsen
- Center for Health Care Improvement, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristine Pape
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord university, Levanger, Norway
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Norberg BL, Johnsen TM, Kristiansen E, Krogh FH, Getz LO, Austad B. Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs. BJGP Open 2024; 8:BJGPO.2023.0095. [PMID: 37907336 PMCID: PMC11169974 DOI: 10.3399/bjgpo.2023.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/23/2023] [Accepted: 08/21/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs. AIM To document GPs' gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway. DESIGN & SETTING A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020. METHOD Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities. RESULTS A total of 1234 (25.4%) of Norway's GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations. CONCLUSION During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits.
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Affiliation(s)
- Børge Lønnebakke Norberg
- Norwegian Centre for E-health Research (NSE) and General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- TillerTorget Medical Centre, Trondheim, Norway
| | - Tor Magne Johnsen
- Norwegian Centre for E-health Research (NSE) and General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Midtbyen Medical Centre, Trondheim, Norway
| | - Eli Kristiansen
- Norwegian Centre for E-health Research (NSE) and General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Frode Helgetun Krogh
- Norwegian Centre for E-health Research (NSE) and General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Linn Okkenhaug Getz
- Norwegian Centre for E-health Research (NSE) and General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Bjarne Austad
- Norwegian Centre for E-health Research (NSE) and General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Wiik AB, Doupe MB, Bakken MS, Kittang BR, Jacobsen FF, Førland O. Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study. BMC Health Serv Res 2024; 24:374. [PMID: 38532452 PMCID: PMC10964583 DOI: 10.1186/s12913-024-10879-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Transferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios. METHODS A Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics. RESULTS Seventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions. CONCLUSIONS Transfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.
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Affiliation(s)
- Arne Bastian Wiik
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway.
| | - Malcolm Bray Doupe
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Marit Stordal Bakken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Bård Reiakvam Kittang
- University of Bergen, Bergen, Norway
- Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Frode Fadnes Jacobsen
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway
| | - Oddvar Førland
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway
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Blinkenberg J, Hetlevik Ø, Sandvik H, Baste V, Hunskaar S. The impact of variation in out-of-hours doctors' referral practices: a Norwegian registry-based observational study. Fam Pract 2023; 40:728-736. [PMID: 36801994 PMCID: PMC10745277 DOI: 10.1093/fampra/cmad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND In a gatekeeping system, the individual doctor's referral practice is an important factor for hospital activity and patient safety. OBJECTIVE The aim of the study was to investigate the variation in out-of-hours (OOH) doctors' referral practice, and to explore these variations' impact on admissions for selected diagnoses reflecting severity, and 30-day mortality. METHODS National data from the doctors' claims database were linked with hospital data in the Norwegian Patient Registry. Based on the doctor's individual referral rate adjusted for local organizational factors, the doctors were sorted into quartiles of low-, medium-low-, medium-high-, and high-referral practice. The relative risk (RR) for all referrals and for selected discharge diagnoses was calculated using generalized linear models. RESULTS The OOH doctors' mean referral rate was 110 referrals per 1,000 consultations. Patients seeing a doctor in the highest referring practice quartile had higher likelihood of being referred to hospital and diagnosed with the symptom of pain in throat and chest, abdominal pain, and dizziness compared with the medium-low quartile (RR 1.63, 1.49, and 1.95). For the critical conditions of acute myocardial infarction, acute appendicitis, pulmonary embolism, and stroke, we found a similar, but weaker, association (RR 1.38, 1.32, 1.24, and 1.19). The 30-day mortality among patients not referred did not differ between the quartiles. CONCLUSIONS Doctors with high-referral practice referred more patients who were later discharged with all types of diagnoses, including serious and critical conditions. With low-referral practice, severe conditions might have been overlooked, although the 30-day mortality was not affected.
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Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
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Myklevoll KR, Zakariassen E, Morken T, Baste V, Blinkenberg J, Bondevik GT. Primary care doctors in acute call-outs to severe trauma incidents in Norway - associations with factors related to patients and doctors. Scand J Prim Health Care 2023; 41:196-203. [PMID: 37256689 PMCID: PMC10478583 DOI: 10.1080/02813432.2023.2216235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/16/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE Severe trauma patients need immediate prehospital intervention and transfer to a specialised trauma hospital. In Norway, primary care doctors (PCDs) are an integrated part of the prehospital trauma care. The aim of this study was to investigate the degree to which PCDs were involved in prehospital care of severe trauma patients and how factors related to patients and doctors were associated with call-outs to these incidents. DESIGN This was a registry-based study in Norway on severe trauma patients with acute hospital admission during the period 2012-2018. SETTING Data was obtained from three Norwegian official registries. SUBJECTS By linking the registries, we studied the actions taken by the PCDs, whether they called out to severe trauma incidents. MAIN OUTCOME MEASURES In multivariable regression models, we investigated whether factors related to the PCDs (age, sex, specialisation in general practice (GP)) and patients (age, sex, duration of hospital stay, type of injury) were associated with call-outs. RESULTS Out of 4342 severe trauma incidents, PCDs had documented involvement in 1683 (39%) and called out to 644 (15%). Increased proportions of PCD call-outs to severe trauma incidents were significantly associated with lower age of PCD, being a GP specialist, lower patient age, being a male patient, increased length of hospital stay and injuries to the head and the neck. CONCLUSIONS PCDs called out to a relatively low proportion of severe trauma patients. Several factors related to patients and doctors were associated with call-outs to severe trauma incidents in Norway.
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Affiliation(s)
- Kristian Rikstad Myklevoll
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Erik Zakariassen
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Tone Morken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Gunnar Tschudi Bondevik
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
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Svedahl ER, Pape K, Austad B, Vie GÅ, Sarheim Anthun K, Carlsen F, Davies NM, Bjørngaard JH. Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study. BMJ Qual Saf 2023; 32:330-340. [PMID: 36522178 DOI: 10.1136/bmjqs-2022-014944] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/12/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To estimate the impact of altering referral thresholds from out-of-hours services on older patients' further use of health services and risk of death. DESIGN Cohort study using patient data from primary and specialised health services and demographic data from Statistics Norway and the Norwegian Cause of Death Registry. SETTING Norway PARTICIPANTS: 491 653 patients aged 65 years and older contacting Norwegian out-of-hours services between 2008 and 2016. ANALYSIS Multivariable adjusted and instrumental variable associations between referrals to hospital from out-of-hours services and further health services use and death for up to 6 months.Physicians' proportions of acute referrals of older, unknown patients from out-of-hours work were used as an instrumental variable ('physician referral preference') for their threshold of referral for such patients whose clinical presentations were less clear cut. RESULTS For older patients, whose referrals could be attributed to their physicians' threshold for referral, mean length of stay in hospital increased 3.30 days (95% CI 3.13 to 3.27) within the first 10 days, compared with non-referred patients. Such referrals also increased 6 months use of outpatient specialist clinics and primary care physicians. Importantly, patients with referrals attributable to their physicians' threshold had a substantially reduced risk of death the first 10 days (HR 0.53, 95% CI 0.31 to 0.91), an effect sustaining through the 6-month follow-up period (HR 0.72, 95% CI 0.54 to 0.97). CONCLUSIONS Out-of-hours patients whose referrals are affected by physician referral threshold contribute substantially to the use of health services. However, the referral seems protective by reducing the risk of death in the first 6 months after the referral. Thus, raising the threshold for referral to lower pressure on overcrowded emergency departments and hospitals should not be encouraged without ensuring the accuracy of the referral decisions, ideally through high-quality randomised controlled trial evidence.
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Affiliation(s)
- Ellen Rabben Svedahl
- Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristine Pape
- Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjarne Austad
- Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnhild Åberge Vie
- Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Fredrik Carlsen
- Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Neil M Davies
- MRC Integrative Epidemiology Unit (IEU), University of Bristol, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
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Lyall MJ, Beckett D, Price A, Strachan MWJ, Jamieson C, Morton C, Begg D, Simpson J, Lone N, Cameron A. Variation in general practice referral rate to acute medicine services and association with hospital admission. A retrospective observational study. Fam Pract 2022; 40:233-240. [PMID: 36063441 PMCID: PMC10047615 DOI: 10.1093/fampra/cmac097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Variation in general practice (GP) referral rates to outpatient services is well described however variance in rates of referral to acute medical units is lacking. OBJECTIVE To investigate variance in GP referral rate for acute medical assessment and subsequent need for hospital admission. METHODS A retrospective cohort study of acute medical referrals from 88 GPs in Lothian, Scotland between 2017 and 2020 was performed using practice population size, age, deprivation, care home residence, and distance from hospital as explanatory variables. Patient-level analysis of demography, deprivation, comorbidity, and acuity markers was subsequently performed on referred and clinically assessed acute medical patients (n = 42,424) to examine how practice referral behaviour reflects clinical need for inpatient hospital care. RESULTS Variance in GP referral rates for acute medical assessment was high (2.53-fold variation 1st vs. 4th quartile) and incompletely explained by increasing age and deprivation (adjusted R2 0.67, P < 0.001) such that significant variance remained after correction for confounders (2.15-fold). Patients from the highest referring quartile were significantly less likely to require hospital admission than those from the third, second, or lowest referring quartiles (adjusted odds ratio 1.28 [1.21-1.36, P < 0.001]; 1.30 [1.23-1.37, P < 0.001]; 1.53 [1.42-1.65, P < 0.001]). CONCLUSIONS High variation in GP practice referral rate for acute medical assessment is incompletely explained by practice population socioeconomic factors and negatively associates with need for urgent inpatient care. Identifying modifiable factors influencing referral rate may provide opportunities to facilitate community-based care and reduce congestion on acute unscheduled care pathways.
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Affiliation(s)
- Marcus J Lyall
- Department of Medicine, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - Dan Beckett
- Department of Acute Medicine, Forth Valley Royal Hospital, Stirling Rd, Larbert FK5 4WR, United Kingdom
| | - Anna Price
- Department of Public Health, Medical Statistician, Western General Hospital, Crewe Rd S, Edinburgh EH4 2XU, United Kingdom
| | - Mark W J Strachan
- Metabolic Unit, Western General Hospital, Crewe Rd S, Edinburgh EH4 2XU, United Kingdom
| | - Clare Jamieson
- Gullane Medical Practice, Hamilton Road, Gullane, East Lothian EH31 2HP, United Kingdom
| | - Catriona Morton
- Craigmillar Medical Group, 106 Niddrie Mains Road, Edinburgh EH16 4DT, United Kingdom
| | - Drummond Begg
- Penicuik Medical Practice, 37 Imrie Place, Penicuik EH26 8LF, United Kingdom
| | - Johanne Simpson
- Department of Medicine, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, United Kingdom
| | - Nazir Lone
- Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, United Kingdom
| | - Allan Cameron
- Department of Acute Medicine, Acute Assessment Unit, Jubilee Building, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom
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