Out-of-hours primary care: a population-based study of the diagnostic scope of telephone contacts

Identifying performance indicators to measure overall performance of telephone triage - a scoping review

OBJECTIVE

This article aims to summarize performance indicators used in telephone triage services research, and make recommendations for the selection of valid indicators to measure the performance of telephone triage. We describe what kind of frameworks, performance indicators, or variables have been used for evaluating telephone triage performance by systematically mapping the telephone triage performance measurement. The objective was to find measures for each Triple Aim dimension.

DESIGN

A scoping review method was used following Joanna Briggs Institute guidelines. Using this method, we defined indicators to measure the performance of telephone triage. We used the Triple Aim framework to identify indicators to measure the overall performance of telephone triage. The Triple Aim framework consists of improving the patient experience of care, improving the health of populations, and reducing cost per capita.

SETTING

The scoping review was performed using CINAHL, Medline, EBSCOhost, and PubMed electronic databases. The eligibility criterion was research published in English between 2015 and 2023. The inclusion focused on the use and performance of telephone triage services and system-focused studies.

RESULTS

A total of 1098 papers were screened for inclusion, with 57 papers included in our review. We identified 13 performance indicators covering all Triple Aim dimensions: waiting times, access, patient satisfaction, the accuracy of triage decision, severity and urgency of the symptoms, triage response, patient compliance with the advice given, follow-up healthcare service use, and running costs of service. We didn't find any earlier framework covering all Triple Aim dimensions properly.

CONCLUSIONS

Measuring the performance of telephone triage requires an extensive and comprehensive approach. We presented performance indicators that may be included in the framework for measuring the performance of telephone triage to support overall performance measurements of telephone triage.

Video triage in calls concerning children with fever at an out-of-hours medical helpline: a prospective quality improvement study

BACKGROUND

Parents often contact out-of-hours services due to worry concerning febrile children, despite the children rarely being severely ill. As telephone triage of children is challenging, many children are referred to hospital assessment. This study investigated if video triage resulted in more children staying at home. Secondary aims included safety, acceptability and feasibility of this new triage tool.

METHODS

In this prospective quality improvement study, nurse call-handlers enrolled febrile children aged 3 months-5 years to video or telephone triage (1:1), with follow-up within 48 h after call. The setting was an out-of-hours call-center for non-urgent illness in Copenhagen, Denmark, receiving over 1 million calls annually and predominately staffed by registered nurses. Main outcome measure was difference in number of children assessed at hospital within 8 h after call between video-and telephone triage group. Rates of feasibility, acceptability and safety (death, lasting means, transfer to intensive care unit) were compared between the triage groups.

RESULTS

There was no difference in triage outcome (home care vs. hospital referral) or number of patients assessed at hospital between triage groups. However, more video triaged patients received in-hospital treatment, testing and hospitalization.

CONCLUSION

Video triage was feasible to conduct, acceptable to parents and as safe as telephone triage. The study did not show that more children stayed at home after video triage, possibly because the allocation strategy was not upheld, as video triage sometimes was chosen in cases of complex and severe symptoms, and this likely has changed study outcome.

TRIAL REGISTRATION

Clinicaltrials.gov.: Id NCT04074239. Registered 2019-08-30. https://clinicaltrials.gov/ct2/show/study/NCT04074239.

Implementation costs of telephone nurse triage service

Telephone nurse triage services are becoming increasingly common in healthcare systems worldwide. Florianópolis (Santa Catarina State, Brazil) is the first municipality in the country to provide this service in its public health system. This study adopted a quantitative, descriptive, and analytical methodology to evaluate the impact of this program on overall costs of the public health system. The research examined all 33,869 calls received by the telephone triage service from March 16 to October 31 in 2020, and calculated the program costs during the period. Avoided cost were calculated by the difference between estimated consultation costs considering patient-stated first alternative and the program recommendation after triage. Analyzing only the costs for the municipality of Florianópolis, the program's costs exceeded avoided costs by almost BRL 2.5 million during the period. By expanding the analysis to include costs of emergency department consultation - not administered by the municipality - based on data from previous research, we found that the program spares BRL 34.59 per call, a 21% cost reduction for the health system. Considering the preliminary results of the study and its limitations, it is understood that the service of telephone nurse triage can reduce costs in the healthcare system.

Patient characteristics and dispatch responses of urinary tract infections in a prehospital setting in Copenhagen, Denmark: a retrospective cohort study

BACKGROUND

Urinary tract infection (UTI) is particularly common in young women and the elderly. The Emergency Medical Services (EMS) in Copenhagen, Denmark can be reached by calling either of two dedicated telephone lines: 1-1-2 in case of an emergency and 1813 during general practitioner's (GP) out-of-office hours (OOH). This study investigated characteristics of patients with symptoms of UTI calling the Copenhagen EMS and the response they received.

METHODS

A retrospective observational cohort study was conducted in which 7.5 years of telephone data on UTI from the EMS in Copenhagen were analyzed. Descriptive statistics and multinomial logistic regression were used to analyze patient characteristics, the timing of the incident and response. Patients' age and gender were assessed and the use of urinary catheters, the timing of the incident, and the impact on the response were evaluated.

RESULTS

A total of 278.961 calls were included (78% female, mean age 47), with an average of 120 patients with UTI symptoms calling each day. Most people contacted the 1813-medical helpline (98%) and of those, the majority were referred to the emergency department (ED)(37%). Patients were more likely to be referred to the ED during the weekend compared to a weekday and less likely during OOH compared to in-office hours (IH). Patients with a urinary catheter were more likely to receive specialized care referred to as 'other'. For the smaller proportion of patients calling 1-1-2, most people got a B (urgent) response (1.5%). The most likely response to be given was an A (emergency) or F (non-emergency) response during OOH compared to IH and on weekends compared to weekdays. Patients with a urinary catheter were more likely to receive a D (unmonitored transport) response.

CONCLUSIONS

Since 2015, there was a decrease in 1813 antibiotic prescription rates and a subsequent increase in referral to the ED of UTI patients. Patients were referred less to the ED during OOH as they were likely to be sent to their GP the next day. During the weekend, patients were referred more to the ED for the likely reason that their GP is closed.

How parents express their worry in calls to a medical helpline: a mixed methods study

Background

Telephone triage is used globally in out-of-hours primary care, to prioritize who needs urgent assessment. Even though children rarely are severely ill, calls about sick children are among the most prevalent, mainly due to parental worry. Pediatric calls are considered challenging, as the call-handler must rely on parents’ second-hand information. We aimed to investigate if parents’ worry can be used as a predictor of severe illness, and if the content of the calls varies between different grades of worry.

Methods

In a convergent mixed methods study design we asked patients to rate their degree-of-worry before talking to a call-handler. We used quantitative data of degree-of-worry, triage- and patient outcome in pediatric calls (n = 2857), and the qualitative content from 54 calls with subsequent hospitalization ≥24 h.

Results

High degree-of-worry was associated with hospitalization ≥24 h (OR 3.33, 95% CI 1.53–7.21). Qualitative findings both confirmed and expanded knowledge of degree-of-worry. Worry was the predominant cause for contact overall, and was mainly triggered by loss-of-control. In calls with high degree-of-worry, the prevalence of loss-of-control was especially high, and the parents had additionally often contacted healthcare services recently. Parents with a foreign accent often rated their worry as high, and these callers were often ignored or interrupted. Calls with low degree-of-worry seemed to occur early during the disease.

Conclusion

High degree of parental worry was associated with severe illness. At the end of calls, call-handlers should ensure that the parent has regained control of the situation to reach increased reassurance and to prevent renewed unnecessary contact. Safety-netting is crucial, as many parents made contact early during the illness and deterioration may develop later. The scoring of parental degree-of-worry may be used as an indicator of potentially severe illness and can easily be implemented at out-of-hours call-centers globally.

Trial registration

Original study registered at clinicaltrials.gov (NCT02979457).

Obstetric Telephone Triage

Objective

Little is known about obstetric telephone triage: the methods used to prioritize the severity of symptoms of obstetric emergency and other unplanned care requests originating by telephone. In large-scale obstetric units, there is a need for an evidence-based triage guideline. The aim of this study was to develop an obstetric guideline for telephonic triage.

Design Setting and Participants

A multi-phase multi-center study was performed with consecutive drafts of the triage guideline using four focus groups, four observations of training sessions and two expert consultations based on the Delphi method. The study was performed in ten hospitals in the Netherlands. The obstetric care professionals involved were gynecologists, midwives, nurses, doctor's assistants, team managers and application managers. After each focus group, each observation and each expert consultation, an interpretative analysis was undertaken. Based on these analyses, the obstetric telephone triage guideline was drafted.

Measurements and Results

The designed guideline describes the primary symptoms presented, five prioritization categories and several descriptors. Consensus (>90%) was reached during the second expert consultation. Fifty-seven (91.9%) participants stated that the obstetric telephone triage guideline was clinically complete, correct, user-friendly and well designed, and 61 (98.4%) participants judged that the newly designed triage guideline was ready to use in daily practice.

Key-Conclusions and Implications for Practice

An evidence-based guideline for obstetric telephone triage was developed through a multi-phase multi-center study with all stakeholders. The guideline was found to be clinically complete, correct, well-designed and user-friendly. It provides a uniform and concrete basis for assessing the severity of the symptoms of obstetric emergency and other unplanned care requests originating by telephone. It also provides a good basis to further develop this evidence-based guideline for telephone triage by continuous registration of all calls.

Does an emergency access button increase the patients' satisfaction and feeling of safety with the out-of-hours health services? A randomised controlled trial in Denmark

OBJECTIVE

To investigate if the option to bypass the telephone queue can increase satisfaction and feeling of safety in callers.

DESIGN

Randomised controlled parallel superiority trial. Data from questionnaire survey.

SETTING

Two out-of-hours (OOH) services in Denmark.

PARTICIPANTS

217 510 citizens who called the OOH services between 4 September 2017 and 30 November 2017.

RANDOMISATION

Two-faze study period: First half with randomisation of participants based on their date of birth; even date randomised to intervention, uneven date randomised to control group. Second half with all participants included in intervention group.

INTERVENTION

Providing randomised callers (intervention group n=146 355) with the option to bypass the telephone waiting line through an emergency access button (EAB), while the rest got the normal service (control group n=71 155). All EAB users were invited to a questionnaire survey as well as random participants who did not use the EAB (of whom approximately 50% did not have the EAB option).

MAIN OUTCOME MEASURES

Satisfaction and feeling of safety in callers.

RESULTS

2208 of 6704 (32.9%) invited callers answered the questionnaire (intervention group n=1415 (users n=621, non-users n=794); control group n=793). The OR for answering in the two categories with highest satisfaction when provided with the EAB option was 1.34 (95% CI 1.07 to 1.68) for satisfaction with the waiting time, 1.21 (95% CI 0.91 to 1.60) for overall satisfaction and 1.46 (95% CI 1.12 to 1.89) for feeling of safety. Approximately 72% (441/621) of EAB users reported that the EAB option increased their feeling of safety with the OOH services 'to a high degree' compared with 25% (197/794) of callers who had the EAB option without using it.

CONCLUSIONS

The EAB can provide fast access to OOH telephone advice in case of severe illness. It favours citizens perceived in most need of urgent healthcare and significantly increases both feeling of safety and patient satisfaction.

TRIAL REGISTRATION DETAILS

NCT02572115 (5 October 2015).

Age-related differences in motives for contacting out-of-hours primary care: a cross-sectional questionnaire study in Denmark

OBJECTIVE

Demands for out-of-hours primary care (OOH-PC) services are increasing. Many citizens call because of non-urgent health problems. Nevertheless, the patients' motives for requesting medical help outside office hours remains an understudied area. This study aimed to examine motives for calling OOH-PC services in various age groups.

DESIGN

Cross-sectional paper based questionnaire study conducted during two weeks in 2015.

SETTING

The OOH-PC services in two Danish regions.

SUBJECTS

Randomly selected patients calling the two healthcare services and accepting to participate in the study received a questionnaire on patient characteristics, health problems, and 26 pre-defined motives based on the Andersen Behavioural Model. Multivariate regression analyses were conducted for various age groups to calculate the probability of each motive to be a significant factor for the decision to call.

RESULTS

A total of 1,871 patients were included in the study; half were parents of children aged 0-12 years. Young adults (18 to 39 years) differed significantly from other age groups as they more often stated perceived barriers and benefits such as "Own GP no time available soon enough" and "Need for quick help because of work".

CONCLUSION

Young adults more often perceive barriers and benefits, which may suggest af difference in expectations regarding the purpose of out-of-hours services and accessibility. Further research is needed to address this issue and further explore the potential gap between the citizens' expectations to the OOH-PC services and the prevailing health policies. Key points The out-of-hours primary healthcare services are increasingly contacted for non-urgent problems, but little is known about the citizens' motives for calling. Age is associated with differences in the perceived importance of various motives for calling out-of-hours care. Young adults are more often than other age groups motivated to call due to logistical issues, such as their job.

Self-rated worry is associated with hospital admission in out-of-hours telephone triage - a prospective cohort study

Objective

Telephone triage manages patient flow in acute care, but a lack of visual cues and vague descriptions of symptoms challenges clinical decision making. We aim to investigate the association between the caller’s subjective perception of illness severity expressed as “degree-of-worry” (DOW) and hospital admissions within 48 h.

Design and setting

A prospective cohort study was performed from January 24th to February 9th, 2017 at the Medical Helpline 1813 (MH1813) in Copenhagen, Denmark. The MH1813 is a primary care out-of-hours service.

Participants

Of 38,787 calls received at the MH1813, 11,338 met the inclusion criteria (caller being patient or close friend/relative and agreement to participate). Participants rated their DOW on a 5-point scale (1 = minimum worry, 5 = maximum worry) before talking to a call handler.

Main outcome measure

Information on hospitalization within 48 h after the call, was obtained from the Danish National Patient Register. The association was assessed using logistic regression in three models: 1) crude, 2) age-and-gender adjusted and 3) age, gender, co-morbidity, reason for calling and caller status adjusted.

Results

A total of 581 participants (5.1%) were admitted to the hospital, of whom 170 (11.3%) presented with a maximum DOW, with a crude odds ratio (OR) for hospitalization of 6.1 (95% confidence interval (CI) 3.9 to 9.6) compared to minimum DOW. Estimates showed dose-response relationship between DOW and hospitalization. In the fully adjusted model, the ORs decreased to 3.1 (95%CI 2.0 to 5.0) for DOW = 5, 3.2 (2.0 to 5.0) for DOW = 4, 1.6 (1.0 to 2.6) for DOW = 3 and 0.8 (0.5 to 1.4) for DOW = 2 compared to minimum DOW.

Conclusion

Patients’ self-assessment of illness severity as DOW was associated with subsequent hospital admission. Further, it may be beneficial in supporting clinical decision making in telephone triage. Finally, it might be useful as a measure to facilitate patient participation in the triage process.

Contact characteristics and factors associated with the degree of urgency among older people in emergency primary health care: a cross-sectional study

Background

As the proportion of older people increases, so will the consumption of health services. The aim of this study was to describe the contact characteristics among older people and to identify factors associated with the degree of urgency at the Norwegian out-of-hours (OOH) emergency primary health care services.

Methods

Inhabitants aged ≥70 years who contacted the OOH service during 2014–2017 in seven OOH districts in Norway were included. We investigated the variables sex, age, time of contact, mode of contact, ICPC-2 based reason for encounter (RFE), priority degree and initial response. We also performed frequency analyses, rate calculations and a log-binomial regression.

Results

A total of 38,293 contacts were registered. The contact rate/1000 inhabitants/year was three times higher in the oldest age group (≥90 years) compared to the youngest age group (70–74 years). Direct attendance accounted for 8.4% of the contacts and 32.8% were telephone contacts from health professionals. The most frequent RFE chapter used was “A General and unspecified” (21.0%) which also showed an increasing rate with higher age. 6.0% of the contacts resulted in a home visit from a doctor. Variables significantly associated with urgent priority degree were RFEs regarding cardiovascular (Relative risk (RR) 1.85; CI 1.74–1.96), neurological (RR 1.55; CI 1.36–1.77), respiratory (RR 1.40; CI 1.30–1.51) and digestive (RR 1.22; CI 1.10–1.34) issues. In addition, telephone calls from health professionals (RR 1.21; CI 1.12–1.31), direct attendance (RR 1.13; CI 1.04–1.22), contacts on weekdays (RR 1.13; CI 1.06–1.20) and contacts from men (RR 1.13; CI 1.09–1.17) were significantly associated with urgent priority degree.

Conclusions

This study provides important information about the Norwegian older inhabitants’ contact with the OOH emergency primary health care services. There are a wide variety of RFEs, and the contact rate is high and increases with higher age. Telephone contact is most common. The OOH staff frequently identify older people as having “general and unspecified” reasons for encounters. OOH nursing staff would benefit from having screening tools and enhanced geriatric training to best support this vulnerable group when these individuals call the OOH service.

Sociodemographic and health-related determinants for making repeated calls to a medical helpline: a prospective cohort study

OBJECTIVES

To identify sociodemographic and health-related characteristics of callers' making repeated calls within 48 hours to a medical helpline, compared with those who only call once.

SETTING

In the Capital Region of Denmark people with acute, non-life-threatening illnesses or injuries are triaged through a single-tier medical helpline for acute, healthcare services.

PARTICIPANTS

People who called the medical helpline between 18 January and 9 February 2017 were invited to participate in the survey. During the period, 38 787 calls were handled and 12 902 agreed to participate. Calls were excluded because of the temporary civil registration number (n=78), the call was not made by the patient or a close relative (n=699), or survey responses were incomplete (n=19). Hence, the analysis included 12 106 calls, representing 11.131 callers' making single calls and 464 callers' making two or more calls within 48 hours. Callers' data (age, sex and caller identification) were collected from the medical helpline's electronic records. Data were enriched using the callers' self-rated health, self-evaluated degree of worry, and registry data on income, ethnicity and comorbidities. The OR for making repeated calls was calculated in a crude, sex-adjusted and age-adjusted analysis and in a mutually adjusted analysis.

RESULTS

The crude logistic regression analysis showed that age, self-rated health, self-evaluated degree of worry, income, ethnicity and comorbidities were significantly associated with making repeated calls. In the mutually adjusted analysis associations decreased, however, odds ratios remained significantly decreased for callers with a household income in the middle (OR=0.71;95% CI 0.54 to 0.92) or highest (OR=0.68;95% CI 0.48 to 0.96) quartiles, whereas immigrants had borderline significantly increased OR (OR=1.34;95% CI 0.96 to 1.86) for making repeated calls.

CONCLUSIONS

Findings suggest that income and ethnicity are potential determinants of callers' need to make additional calls within 48 hours to a medical helpline with triage function.

The response of health systems to after-hours primary cares in Iran and the selected countries

BACKGROUND

After-hours primary care often involves care required for medical conditions managed outside hospitals by a general practitioner. After-hours care aims at meeting the urgent needs of patients who cannot wait to visit their general practitioner in office hours.

AIM

The present study aims at comparing the after-hours primary cares in Iran, Turkey, the United States, the Netherlands, Australia, and the United Kingdom.

METHOD

This is a descriptive-comparative study comparing after-hours primary cares in Iran and selected countries in 2019. Considering the research purpose, data pertaining to each country were collected from valid information sources and the countries were compared based on the comparative table. A framework analysis was used for data analyses.

RESULTS

The results were stated regarding the model type, dominant model, payments mechanism, the support of insurance organizations, service tariffs, private sector participation, and participation of primary care general practitioners in each country.

CONCLUSIONS

Different countries are using diverse policies to enhance patients' access to general practitioners in out-of-office hours. In Iran, however, due to the lack of specific policies to access after-hour primary cares, people have to use expensive hospital and private cares. An essential step in solving this problem is the availability of general practitioner services at primary care level.

Do callers to out-of-hours care misuse an option to jump the phone queue?

Objectives: Out-of-hours (OOH) services provide access to healthcare outside normal office hours, but the waiting time can sometimes be long. All callers must wait in the telephone queue, even if the health problem is urgent or life-threatening. We tested an emergency access button (EAB), which allowed callers with perceived severe health problems to bypass the queue. We aimed to investigate the severity of the health problems and the relevance of EAB use (assessed by triage professionals). Additionally, we aimed to calculate the number of suspected acute myocardial infarctions (AMI) and ambulance dispatches. Design: Descriptive study of a randomized intervention. Setting: OOH services in two major Danish healthcare regions. Subjects: 217,510 callers participated; 146,355 were randomized to intervention, and 6554 of 6631 (98.8%) questionnaires were completed by OOH triage professionals. Intervention: An EAB allowing randomly selected callers to bypass the telephone queue. Main outcome measures: Severity of contact and relevance of EAB use. Number of suspected AMIs and ambulance dispatches. Results: In both settings, contacts with EAB use concerned significantly more severe health problems than contacts without EAB use (p < 0.001). Triage professionals rated EAB use as "not relevant" in 23% of cases. Significantly more EAB users (10.4%) than EAB non-users (3.3% with EAB option and 1.7% without EAB option, p < 0.001) had a suspected AMI. Conclusions: We found higher proportions of severe health problems, suspected AMIs, and ambulance dispatches among EAB users. Only 23% of EAB use was rated "not relevant". This suggests that the EAB is used as intended. Key points Out-of-hours healthcare is challenged by increasing demand and long triage waiting times. An emergency access button may allow severely ill callers to jump the queue. Callers who bypassed the queue were more severely ill than callers who did not bypass the queue. Only 23% of bypassers presented "not relevant" health problems according to the triage staff.Trial registration: Identifier NCT02572115 registered at Clinicaltrials.gov on 5 October 2015.

Giving callers the option to bypass the telephone waiting line in out-of-hours services: a comparative intervention study

OBJECTIVE

Acute out-of-hours (OOH) healthcare is challenged by potentially long waiting time for callers in acute need of medical aid. OOH callers must usually wait in line, even when contacting for highly urgent or life-threatening conditions. We tested an emergency access button (EAB), which allowed OOH callers to bypass the waiting line if they perceived their health problem as severe. We aimed to investigate EAB use and patient characteristics associated with this use.

DESIGN

Comparative intervention study.

SETTING

OOH services in two major Danish healthcare regions.

INTERVENTION

Giving callers the option to bypass the telephone waiting line by introducing an EAB.

PARTICIPANTS

OOH service callers contacting during end of October to mid-December 2017.

MAIN OUTCOME MEASURES

Proportions of EAB use, waiting time and background information on participants in two settings differing on organisation structure, waiting time and triage personnel.

RESULTS

In total, 97,791 out of 158,784 callers (61.6%) chose to participate. The EAB was used 2905 times out of 97,791 (2.97%, 95%CI 2.86; 3.08). Patient characteristics associated with increased EAB use were male gender, higher age, low education, being retired, and increasing announced estimated waiting time. In one region, immigrants used the EAB more often than native Danish callers.

CONCLUSION

Only about 3% of all callers chose to bypass the waiting line in the OOH service when given the option. This study suggests that the EAB could serve as a new and simple tool to reduce the waiting time for severely ill patients in an OOH service telephone triage setting. Key Points Acute out-of-hours healthcare is challenged by overcrowding and increasing demand for services. This study shows that only approximately 3% of callers chose to bypass the telephone waiting queue when given the opportunity through an emergency access button. An emergency access button may serve as a new tool to help reduce the triage waiting time for severely ill patients in out-of-hours medical facilities.

Statistical complexity of reasons for encounter in high users of out of hours primary care: analysis of a national service

Background

Managing demand for urgent and unscheduled care is a major problem for health services globally. A particular issue is that some patients appear to make heavy use of services, including primary care out of hours. We hypothesised that greater variation (statistical complexity) in reasons for attending primary care out of hours services may be a useful marker of patients at high risk of ongoing heavy service use.

Methods

We analysed an anonymised dataset of contacts with the primary care out of hours care for Scotland in 2011. This contained 120,395 contacts from 13,981 high-using patients who made 5 or more contacts during a calendar year. We allocated the stated reason for each encounter into one of 14 categories. For each patient we calculated measures of statistical complexity of reasons for encounter including the count of different categories, Herfindahl index and statistical entropy of either the categories themselves, or the category transitions. We examined the association of these measures of statistical complexity with patient and healthcare use characteristics.

Results

The high users comprised 2.4% of adults using the service and accounted for 15% of all contacts. Statistical complexity (as entropy of categories) increased with number of contacts but was not substantially influenced by either patient age or sex. This lack of association with age was unexpected as with increasing multi-morbidity one would expect greater variability in reason for encounter. Between 5 and 10 consultations, higher entropy was associated with a reduced likelihood of further consultations. In contrast, the occurrence of one or more contacts for a mental health problem was associated with increased likelihood of further consultations.

Conclusion

Complexity of reason for encounter can be estimated in an out of hours primary care setting. Similar levels of statistical complexity are seen in younger and older adults (suggesting that it is more to do with consultation behaviour than morbidity) but it is not a predictor of ongoing high use of urgent care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3938-z) contains supplementary material, which is available to authorized users.

Breathlessness in the primary care setting

PURPOSE OF REVIEW

Breathlessness is a high-volume problem with 10% of adults experiencing the symptom daily placing a heavy burden on the health and wider economy. As it worsens, they enter the specialist and hospital-based symptom services where costs quickly escalate and people may find themselves in a place not of their choosing. For many, their care will be delivered by a disease or organ specialist and can find themselves passing between physicians without coordination for symptom support. General practitioners (GPs) will be familiar with this scenario and can often feel out of their depth. Recent advances in our thinking about breathlessness symptom management can offer opportunities and a sense of hope when the GP is faced with this situation.

RECENT FINDINGS

Original research, reviews and other findings over the last 12-18 months that pertain to the value that general practice and the wider primary care system can add, include opportunities to help people recognize they have a problem that can be treated. We present systems that support decisions made by primary healthcare professionals and an increasingly strong case that a solution is required in primary care for an ageing and frail population where breathlessness will be common.

SUMMARY

Primary care practitioners and leaders must start to realize the importance of recognizing and acting early in the life course of the person with breathlessness because its impact is enormous. They will need to work closely with public health colleagues and learn from specialists who have been doing this work usually with people near to the end of life translating the skills and knowledge further upstream to allow people to live well and remain near home and in their communities.

Preschool children in out-of-hours primary care - a questionnaire-based cross-sectional study of factors related to the medical relevance of health problems

Background

Out-of-hours primary care (OOH-PC) is intended to provide medical care services for health problems that cannot wait until normal office hours. Children under five years of age represent about 19% of all OOH-PC contacts in Denmark, and the frequency of calls assessed as severe by health professionals is markedly lower for children than for other age groups. Several studies have questioned the appropriateness of the parents’ use of OOH-PC. We aimed to identify factors associated with calls from parents of pre-school children concerning perceived non-severe health problems that were ranked by the triaging GPs as more appropriate for GP office hours (defined as ‘medically irrelevant’).

Methods

We used data from a cross-sectional study performed in the Central Denmark Region for a 1-year period during 2010–2011. GPs in the OOH-PC assessed random contacts, and a questionnaire was subsequently sent to registered patients. Associations between different factors and the medical irrelevance of contacts were estimated with a generalised linear model to calculate the prevalence ratio (PR).

Results

Among all included 522 telephone consultations and 1226 face-to-face consultations, we identified 71 (13.6%) telephone consultations and 95 (7.8%) face-to-face consultations that were both assessed as non-severe by the parents and more appropriate for GP office hours by the GPs. For telephone consultations, contacts at other times than 4–8 pm on weekdays were statistically significantly associated with medical irrelevance. Additionally, symptoms of longer duration than 24 h were statistically significantly associated medical irrelevance.

Conclusions

A large part of the calls to the Danish OOH-PC concern children. The results indicate that some of these calls are made for other than strictly medical reasons. To achieve more effective use of available resources, it might seem relevant to aim at directing more contacts directly to daytime care. However, future studies to enhance our knowledge on parents’ motivation and behaviour would be recommendable.

Telephone counselling by nurses in Norwegian primary care out-of-hours services: a cross-sectional study

Background

The primary care out-of-hours (OOH) services in Norway are characterized by high contact rates by telephone. The telephone contacts are handled by local emergency medical communication centres (LEMCs), mainly staffed by registered nurses. When assessment by a medical doctor is not required, the nurse often handles the contact solely by nurse telephone counselling. Little is known about this group of contacts. Thus, the aim of this study was to investigate characteristics of encounters with the OOH services that are handled solely by nurse telephone counselling.

Methods

Nurses recorded ICPC-2 reason for encounter (RFE) codes and patient characteristics of all patients who contacted six primary care OOH services in Norway during 2014. Descriptive statistics and frequency analyses were applied.

Results

Of all telephone contacts (n = 61,441), 23% were handled solely by nurse counselling. Fever was the RFE most frequently handled (7.3% of all nurse advice), followed by abdominal pain, cough, ear pain and general symptoms. Among the youngest patients, 32% of the total telephone contacts were resolved by nurse advice compared with 17% in the oldest age group. At night, 31% of the total telephone contacts were resolved solely by nurse advice compared with 21% during the day shift and 23% in the evening. The share of nurse advice was higher on weekdays compared to weekends (mean share 25% versus 20% respectively).

Conclusion

This study shows that nurses make a significant contribution to patient management in the Norwegian OOH services. The findings indicate which conditions nurses should be able to handle by telephone, which has implications for training and routines in the LEMCs. There is the potential for more nurse involvement in several of the RFEs with a currently low share of nurse counselling.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0651-z) contains supplementary material, which is available to authorized users.

Reasons for encounter by different levels of urgency in out-of-hours emergency primary health care in Norway: a cross sectional study

BACKGROUND

Frequencies of reasons for encounter (RFEs) in emergency primary care out-of-hours (OOH) services are relevant for planning of capacities as well as to target the training of staff at casualty clinics. We aimed to present frequencies of RFEs in the different organ systems, and to identify the most frequent RFEs at different urgency levels.

METHODS

We analyzed data on RFEs in Norwegian OOH services. International Classification of Primary Care (ICPC-2) RFE codes were recorded in all contacts to eight representative OOH casualty clinics in 2014 and 2015 covering 20 municipalities with a total population of 260 196. Frequencies of each ICPC-2 chapters and groups of ICPC-2 codes were calculated at different urgency levels.

RESULTS

Musculoskeletal, respiratory, skin, digestive and general and unspecified issues were the most frequent RFE groups. Fever was the most frequent single ICPC-2 RFE code, but was less common among the most urgent cases. Abdominal pain was the most common RFE in patients with yellow urgency level (urgent), and chest pain dominated the potentially red (potentially life threatening) cases. There was less variation in the use of ICPC-2 with increasing urgency level.

CONCLUSIONS

This study identifies important differences in RFEs between urgency levels in the Norwegian OOH services. The findings provide new insight into the function of the primary health care emergency services in the Norwegian health care system, and should have implications for staffing, training and equipment in the OOH services.