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Schrimpf A, Scheiwe E, Bleckwenn M. Insights from end-of-career general practitioners on changing working conditions and generational differences: considerations for future strategies. BMC PRIMARY CARE 2024; 25:171. [PMID: 38762452 PMCID: PMC11102275 DOI: 10.1186/s12875-024-02419-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
The landscape of general practice has experienced notable transformations in recent decades, profoundly influencing the working conditions of general practitioners (GPs). This study aimed to examine the most salient changes affecting GPs' daily practices. Through semi-structured qualitative interviews with 15 end-of-career GPs, the study explored how these changes affected work organization, equipment, working hours, work-life balance, job satisfaction, training, patient relationships, and reputation. The interviews revealed that these changes were perceived as barriers, opportunities, or a complex interplay of both for general practice. While the interviewed GPs valued technological advancements and reported positive developments in working conditions, challenges included a gradual reduction in the range of tasks, growing administrative burdens, and less practical training for young physicians. Other changes, such as new doctor-patient dynamics, the transition from single to group practice, and differing professional expectations of the younger generation, were seen as both challenging and strengthening for general practice. By combining these factors and trade-offs observed by end-of-career GPs in our study over the past few decades with general societal changes, we provide ideas for the design of future framework conditions in general practice that might enhance the attractiveness of the profession. These insights offer key considerations that can guide future strategies for general practice and medical education.
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Affiliation(s)
- Anne Schrimpf
- Institute for General Practice, Faculty of Medicine, Leipzig University, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany.
| | - Elisabeth Scheiwe
- Institute of General Practice and Family Medicine, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Markus Bleckwenn
- Institute for General Practice, Faculty of Medicine, Leipzig University, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
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Verzantvoort NCM, Teunis T, Verheij TJM, van der Velden AW. Self-triage for acute primary care via a smartphone application: Practical, safe and efficient? PLoS One 2018; 13:e0199284. [PMID: 29944708 PMCID: PMC6019095 DOI: 10.1371/journal.pone.0199284] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/05/2018] [Indexed: 11/19/2022] Open
Abstract
Background Since the start of out-of-hours (OOH) primary care clinics, the number of patient consultations has been increasing. Triage plays an important role in patient selection for a consultation, and in providing reassurance and self-management advice. Objective We aimed to investigate whether the smartphone application “Should I see a doctor?” (in Dutch:”moet ik naar de dokter?”) could guide patients in appropriate consultation at OOH clinics by focusing on four topics: 1) app usage, 2) user satisfaction, 3) whether the app provides the correct advice, and 4) whether users intend to follow the advice. Design and setting A prospective, cross-sectional study amongst app users in a routine primary care setting. Methods The app is a self-triage tool for acute primary care. A built-in questionnaire asked users about the app’s clarity, their satisfaction and whether they intended to follow the app’s advice (n = 4456). A convenience sample of users was phoned by a triage nurse (reference standard) to evaluate whether the app’s advice corresponded with the outcome of the triage call (n = 126). Suggestions of phoned participants were listed. Results The app was used by patients of all ages, also by parents for their children, and mostly for abdominal pain, skin disorders and cough. 58% of users received the advice to contact the clinic, 34% a self-care advice and 8% to wait-and-see. 65% of users intended to follow the app’s advice. The app was rated as ‘neutral’ to ‘very clear’ by 87%, and 89% were ‘neutral’ to ‘very satisfied’. In 81% of participants the app’s advice corresponded to the triage call outcome, with sensitivity, specificity, positive- and negative predictive values of 84%, 74%, 88% and 67%, respectively. Conclusion The app “Should I see a doctor?” could be a valuable tool to guide patients in contacting the OOH primary care clinic for acute care. To further improve the app’s safety and efficiency, triaging multiple symptoms should be facilitated, and more information should be provided to patients receiving a wait-and-see advice.
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Affiliation(s)
- Natascha C. M. Verzantvoort
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Teun Teunis
- Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Theo J. M. Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- * E-mail:
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Population and patient factors affecting emergency department attendance in London: retrospective cohort analysis of linked primary and secondary care records. Br J Gen Pract 2018; 68:e157-e167. [PMID: 29335325 DOI: 10.3399/bjgp18x694397] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/11/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Population factors, including social deprivation and morbidity, predict the use of emergency departments (EDs). AIM To link patient-level primary and secondary care data to determine whether the association between deprivation and ED attendance is explained by multimorbidity and other clinical factors in the GP record. DESIGN AND SETTING Retrospective cohort study based in East London. METHOD Primary care demographic, consultation, diagnostic, and clinical data were linked with ED attendance data. GP Patient Survey (GPPS) access questions were linked to practices. RESULTS Adjusted multilevel analysis for adults showed a progressive rise in ED attendance with increasing numbers of long-term conditions (LTCs). Comparing two LTCs with no conditions, the odds ratio (OR) is 1.28 (95% confidence interval [CI] = 1.25 to 1.31); comparing four or more conditions with no conditions, the OR is 2.55 (95% CI = 2.44 to 2.66). Increasing annual GP consultations predicted ED attendance: comparing zero with more than two consultations, the OR is 2.44 (95% CI = 2.40 to 2.48). Smoking (OR 1.30, 95% CI = 1.28 to 1.32), being housebound (OR 2.01, 95% CI = 1.86 to 2.18), and age also predicted attendance. Patient-reported access scores from the GPPS were not a significant predictor. For children, younger age, male sex, white ethnicity, and higher GP consultation rates predicted attendance. CONCLUSION Using patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.
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Turnbull J, Prichard J, Pope C, Brook S, Rowsell A. Risk work in NHS 111: the everyday work of managing risk in telephone assessment using a computer decision support system. HEALTH RISK & SOCIETY 2017. [DOI: 10.1080/13698575.2017.1324946] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Joanne Turnbull
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jane Prichard
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Catherine Pope
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Simon Brook
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Alison Rowsell
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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Nørøxe KB, Huibers L, Moth G, Vedsted P. Medical appropriateness of adult calls to Danish out-of-hours primary care: a questionnaire-based survey. BMC FAMILY PRACTICE 2017; 18:34. [PMID: 28292257 PMCID: PMC5351208 DOI: 10.1186/s12875-017-0617-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 03/07/2017] [Indexed: 11/28/2022]
Abstract
Background Optimal utilisation of the out-of-hours primary care (OOH-PC) services remains a concern in public health policy. We need more knowledge on potentially avoidable contacts. This study examines the frequency of medically assessed inappropriate OOH-PC calls from adults, explores factors associated with such assessment, and examines the relation to patient-assessed severity of health problem and fulfilment of expectations. Methods We performed secondary analyses of data from a large cross-sectional survey on contacts to Danish OOH-PC. As access to Danish OOH-PC is provided through telephone triage delivered by a general practitioner (GP), we included only telephone contacts. A contact was characterised as medically inappropriate when the triage GP assessed that the request from a medical perspective should have been directed to daytime primary care. Appropriateness was examined in relation to patient characteristics, reason for encounter, time of contact, and whether the contact was triaged to a face-to-face consultation, and in relation to patient-assessed severity of the health problem and fulfilment of expectations. Associations were estimated with odds ratios (ORs) using multivariate analysis. Results Of all contacts, 23.7% were assessed as medically inappropriate. Such assessment was associated with: younger age, longer symptom duration, exacerbation of chronic condition, and contact only few hours away from own GP’s office hours. Of medically inappropriate contacts, 31.3% were from patients aged 18–30 years, 41.5% concerned symptoms of > 24 h, 19.4% concerned exacerbation of chronic condition, and 21.3% were calls < 3 h away from own GP’s regular office hours. Medicine request was the most frequent reason for an inappropriate contact (14.3% of medically inappropriate contacts). In 53.4% of contacts assessed as inappropriate, the health problem was considered as severe by patients and medical assessed inappropriateness was significantly associated with unfulfilled patient expectations. Conclusions One in four OOH-PC calls was considered medically inappropriate. Future efforts to reduce suboptimal use of OOH-PC should focus on the types of contacts with the highest optimisation potential, e.g., medication requests, long-lasting symptoms, and exacerbations. Such interventions should aim at bridging the gap between the GP’s medical assessment and the patient’s expectations to appropriate OOH-PC use.
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Affiliation(s)
- Karen Busk Nørøxe
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, 8000, Aarhus C, Denmark.
| | - Linda Huibers
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, 8000, Aarhus C, Denmark
| | - Grete Moth
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, 8000, Aarhus C, Denmark
| | - Peter Vedsted
- Department of Public Health, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, 8000, Aarhus C, Denmark
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Giezendanner S, Jung C, Banderet HR, Otte IC, Gudat H, Haller DM, Elger BS, Zemp E, Bally K. General Practitioners' Attitudes towards Essential Competencies in End-of-Life Care: A Cross-Sectional Survey. PLoS One 2017; 12:e0170168. [PMID: 28146566 PMCID: PMC5287469 DOI: 10.1371/journal.pone.0170168] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 12/30/2016] [Indexed: 12/04/2022] Open
Abstract
Background Identifying essential competencies in end-of-life care, as well as general practitioners’ (GPs) confidence in these competencies, is essential to guide training and quality improvement efforts in this domain. Aim To determine which competencies in end-of-life care are considered important by GPs, to assess GPs’ confidence in these competencies in a European context and their reasons to refer terminally ill patients to a specialist. Design and Setting Cross-sectional postal survey involving a stratified random sample of 2000 GPs in Switzerland in 2014. Method Survey development was informed by a previous qualitative exploration of relevant end-of-life GP competencies. Main outcome measures were GPs’ assessment of the importance of and confidence in 18 attributes of end-of-life care competencies, and reasons for transferring care of terminally-ill patients to a specialist. GP characteristics associated with main outcome measures were tested using multivariate regression models. Results The response rate was 31%. Ninety-nine percent of GPs considered the recognition and treatment of pain as important, 86% felt confident about it. Few GPs felt confident in cultural (16%), spiritual (38%) and legal end-of-life competencies such as responding to patients seeking assisted suicide (35%) although more than half of the respondents regarded these competencies as important. Most frequent reasons to refer terminally ill patients to a specialist were lack of time (30%), better training of specialists (23%) and end-of-life care being incompatible with other duties (19%). In multiple regression analyses, confidence in end-of-life care was positively associated with GPs’ age, practice size, home visits and palliative training. Conclusions GPs considered non-somatic competencies (such as spiritual, cultural, ethical and legal aspects) nearly as important as pain and symptom control. Yet, few GPs felt confident in these non-somatic competencies. These findings should inform training and quality improvement efforts in this domain, in particular for younger, less experienced GPs.
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Affiliation(s)
| | - Corinna Jung
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | | | - Ina Carola Otte
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Heike Gudat
- Hospiz im Park, Hospital for Palliative Care, Arlesheim, Basel District, Switzerland
| | - Dagmar M. Haller
- Primary Care Unit, University of Geneva, Geneva, Switzerland
- Department of General Practice, the University of Melbourne, Melbourne, Victoria, Australia
| | - Bernice S. Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- Center of Legal Medicine, University of Geneva, Geneva, Switzerland
| | - Elisabeth Zemp
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Klaus Bally
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
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Perez I, Brown M, Pinchin J, Martindale S, Sharples S, Shaw D, Blakey J. Out of hours workload management: Bayesian inference for decision support in secondary care. Artif Intell Med 2016; 73:34-44. [DOI: 10.1016/j.artmed.2016.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/29/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
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Abstract
Background It is not convenient or always possible to address parent requests for prescription refills after hours. The primary objective of this quality improvement study was to decrease the number of refill requests received outside of regular business hours. A secondary objective was to reduce the negative effects of call fatigue and related exhaustion for physicians taking calls. Methods Voluntary participation in this quality improvement project was solicited from the Child Neurology Division at a single academic, tertiary, metropolitan children's hospital. Study design was developed from a project charter, fishbone diagram, process map, driver diagram, and plan-do-study-act worksheet. A peer-reviewed letter was mailed to all clinic patient families and signs were displayed in the clinic space as notification of a policy change. A peer-reviewed script was provided to the Children's Mercy Contact Center triage personnel addressing after-hours refill requests. The number of refill requests received during each after-hours call shift was recorded from April 1, 2015, to March 31, 2016, with a primary outcome measure of the monthly number of refill requests. Results Postintervention, the average number of refill requests after hours decreased by 39% from 21 to 11 per month (p = 0.0055). Conclusions This simple intervention has promise to limit prescription refill requests made after hours and improve physician quality of life. Continued data collection will help establish the sustainability of the effect made by this intervention.
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Affiliation(s)
| | - Keith A Coffman
- Division of Child Neurology, Children's Mercy, Kansas City, MO
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Moth G, Huibers L, Christensen MB, Vedsted P. Out-of-hours primary care: a population-based study of the diagnostic scope of telephone contacts. Fam Pract 2016; 33:504-9. [PMID: 27328678 DOI: 10.1093/fampra/cmw048] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND GPs answer all patient calls to the out-of-hours primary care (OOH-PC) services in Denmark. Knowledge is scarce on how the triage-GPs act on the specific reasons for encounter (RFE). OBJECTIVE This study aims to describe the RFEs, the applied diagnoses and the severity of health problems presented in calls to the OOH-PC. METHODS This was a 1-year cross-sectional study based on IT-integrated pop-up questionnaires addressing patients' health problems. We included only telephone contacts that were categorized according to their triage outcome as telephone consultations, direct admissions to hospital or referrals for face-to-face contact. The GP-assessed severity was calculated for age groups and types of outcome. We identified the 20 most frequent primary RFEs and diagnoses for each type of contact termination. RESULTS We included 7810 telephone calls. Calls considered non-severe made up two-thirds of the calls terminated as telephone consultations, whereas calls considered potentially severe made up the main part of referrals (52.3%). Overall, the 20 most frequent RFEs accounted for 45.2% of all RFEs, fever being the most frequent (10.0%). Some RFEs were terminated mostly as telephone consultations [e.g. insect bite/sting (75.9%)], whereas others were most often referred for a face-to-face contact [i.e. dyspnoea (79.1%)] or directly to hospital [i.e. chest pain (29.4%)]. CONCLUSION The distribution of the RFEs on triage outcomes, dominated by more severe diagnoses in referrals indicates a suitable referral level. However, future research on factors related to the demanding task of telephone triage is highly relevant for postdoctoral training of GPs.
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Affiliation(s)
- Grete Moth
- The Research Unit for General Practice, Aarhus University, Aarhus, Denmark.
| | - Linda Huibers
- The Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | | | - Peter Vedsted
- The Research Unit for General Practice, Aarhus University, Aarhus, Denmark
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Ehrich K. Reconceptualizing ‘Inappropriateness’: Researching Multiple Moral Positions in Demand for Primary Healthcare. Health (London) 2016. [DOI: 10.1177/1363459303007001621] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In a recently completed study of the management of ‘out-ofhours’ primary healthcare for children and ways in which judgements are made about legitimate access, the construct of ‘inappropriate demand’ is investigated. This seemingly intractable health care issue has not been resolved by research that rests on a one-sided conceptualization of the ‘problem’. In practice, ‘demand’ arises within complex processes of interaction between people taking a range of moral positions in particular contexts. This is illustrated with interpretations of some ethnographic material from the study. An argument is made for an alternative research approach to such contentious issues that acknowledges multiple and latent moral orientations, and reveals moral judgements in scientific guise.
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Glasper A. Can the NHS become a 7-day service for all? BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2015; 24:706-707. [PMID: 26153812 DOI: 10.12968/bjon.2015.24.13.706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Alan Glasper
- Emeritus professor at the University of Southampton, discusses the launch of a new campaign by the Prime Minister in which he pledges his Government's commitment to providing free health care for all, wherever and whenever they need it
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Buja A, Toffanin R, Rigon S, Sandonà P, Carraro D, Damiani G, Baldo V. Out-of-hours primary care services: demands and patient referral patterns in a Veneto region (Italy) Local Health Authority. Health Policy 2015; 119:437-46. [PMID: 25620776 DOI: 10.1016/j.healthpol.2015.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 12/05/2014] [Accepted: 01/05/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to describe the characteristics of patients admitted to an out-of-hours (OOH) service and to analyze the related outputs. SETTING A retrospective population-based cohort study was conducted by analyzing an electronic database recording 23,980 OOH service contacts in 2011 at a Local Health Authority in the Veneto Region (North-East Italy). METHOD A multinomial logistic regression was used to compare the characteristics of contacts handled by the OOH physicians with cases referred to other services. RESULTS OOH service contact rates were higher for the oldest and youngest age groups and for females rather than males. More than half of the contacts concerned patients who were seen by a OOH physician. More than one in three contacts related problems managed over the phone; only ≈10% of the patients were referred to other services. Many factors, including demographic variables, process-logistic variables and clinical characteristics of the contact, were associated with the decision to visit the patient's home (rather than provide telephone advice alone), or to refer patients to an ED or to a specialist. Our study demonstrated, even after adjusting, certain OOH physicians were more likely than their colleagues to refer a patient to an ED. CONCLUSION Our study shows that OOH services meet composite and variously expressed demands. The determining factors associated with cases referred to other health care services should be considered when designing clinical pathways in order to ensure a continuity of care. The unwarranted variability in OOH physicians' performance needs to be addressed.
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Affiliation(s)
- Alessandra Buja
- Dipartimento di Medicina Molecolare, Sezione di Sanità Pubblica, Laboratorio di Sanità Pubblica e Studi di Popolazione, Università di Padova, Italy.
| | | | - Stefano Rigon
- Direzione Sanitaria, Azienda ULSS 4, Regione Veneto, Italy
| | - Paolo Sandonà
- Scuola di Specializzazione in Igiene e Medicina Preventiva, Università di Padova, Italy
| | | | - Gianfranco Damiani
- Facoltà di Medicina, Departmemt of Public Health, Università Cattolica del Sacro Cuore, Italy
| | - Vincenzo Baldo
- Dipartimento di Medicina Molecolare, Sezione di Sanità Pubblica, Laboratorio di Sanità Pubblica e Studi di Popolazione, Università di Padova, Italy
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Huibers L, Moth G, Andersen M, van Grunsven P, Giesen P, Christensen MB, Olesen F. Consumption in out-of-hours health care: Danes double Dutch? Scand J Prim Health Care 2014; 32:44-50. [PMID: 24635578 PMCID: PMC4137903 DOI: 10.3109/02813432.2014.898974] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To study the quantitative consumption in out-of-hours (OOH) primary care in Denmark and the Netherlands, in the context of OOH care services. DESIGN A retrospective observational study describing contacts with OOH care services, using registration data. SETTING OOH care services (i.e. OOH primary care, emergency department, and ambulance care) in one Danish and one Dutch region. SUBJECTS All patients contacting the OOH care services in September and October 2011. MAIN OUTCOME MEASURES Consumption as number of contacts per 1000 inhabitants in total and per age group per contact type. RESULTS For the two-month period the Danes had 80/1000 contacts with OOH primary care compared with 50/1000 for the Dutch. The number of contacts per 1000 inhabitants per age group varied between the regions, with the largest difference in the 0-5 years age group and a considerable difference in the young-adult groups (20-35 years). The difference was largest for telephone consultations (47/1000 vs. 20/1000), particularly in the youngest age group (154/1000 vs. 39/1000). The Danes also had more home visits than the Dutch (10/1000 vs. 5/1000), while the Dutch had slightly more clinic consultations per 1000 inhabitants than the Danes (25/1000 vs. 23/1000). CONCLUSION The Danish population has more contacts with OOH primary care, particularly telephone consultations, especially concerning young patients. Future research should focus on the relevance of contacts and identification of factors related to consumption in OOH primary care.
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Affiliation(s)
- Linda Huibers
- Research Unit for General Practice, Department of Public
Health, Aarhus University, Denmark
- Scientific Institute for Quality of Healthcare, Radboud
University Medical Center, The Netherlands
| | - Grete Moth
- Research Unit for General Practice, Department of Public
Health, Aarhus University, Denmark
| | - Mikkel Andersen
- Research Department Prehospital Emergency Medical
Services, Aarhus, Denmark, and
Department of Clinical Epidemiology, Aarhus University Hospital,
Denmark
| | | | - Paul Giesen
- Scientific Institute for Quality of Healthcare, Radboud
University Medical Center, The Netherlands
| | | | - Frede Olesen
- Research Unit for General Practice, Department of Public
Health, Aarhus University, Denmark
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Elshout G, van Ierland Y, Bohnen AM, de Wilde M, Moll HA, Oostenbrink R, Berger MY. Alarming signs and symptoms in febrile children in primary care: an observational cohort study in The Netherlands. PLoS One 2014; 9:e88114. [PMID: 24586305 PMCID: PMC3929539 DOI: 10.1371/journal.pone.0088114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 01/04/2014] [Indexed: 11/18/2022] Open
Abstract
CONTEXT Febrile children in primary care have a low risk for serious infection. Although several alarming signs and symptoms are proposed to have predictive value for serious infections, most are based on research in secondary care. The frequency of alarming signs/symptoms has not been established in primary care; however, in this setting differences in occurrence may influence their predictive value for serious infections. OBJECTIVE To determine the frequency of alarming signs/symptoms in febrile children in primary care. DESIGN Observational cohort study. Clinical information was registered in a semi-structured way and manually recoded. SETTING General practitioners' out-of-hours service. SUBJECTS Face-to-face patient contacts concerning children (aged ≤16 years) with fever were eligible for inclusion. MAIN OUTCOME MEASURES Frequency of 18 alarming signs and symptoms as reported in the literature. RESULTS A total of 10,476 patient contacts were included. The frequency of alarming signs/symptoms ranged from n = 1 (ABC instability; <0.1%) to n = 2,207 (vomiting & diarrhea; 21.1%). Of all children, 59.7% had one or more alarming signs and/or symptoms. Several alarming signs/symptoms were poorly registered with the frequency of missing information ranging from 1,347 contacts (temperature >40°C as reported by the parents; 12.9%) to 8,647 contacts (parental concern; 82.5%). CONCLUSION Although the prevalence of specific alarming signs/symptoms is low in primary care, ≥50% of children have one or more alarming signs/symptoms. There is a need to determine the predictive value of alarming signs/symptoms not only for serious infections in primary care, but as well for increased risk of a complicated course of the illness.
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Affiliation(s)
- Gijs Elshout
- Department of General Practice, Erasmus MC, Rotterdam, the Netherlands
| | - Yvette van Ierland
- Department of General Pediatrics, Erasmus MC – Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arthur M. Bohnen
- Department of General Practice, Erasmus MC, Rotterdam, the Netherlands
| | - Marcel de Wilde
- Department of Medical Informatics, Erasmus MC, Rotterdam, the Netherlands
| | - Henriëtte A. Moll
- Department of General Pediatrics, Erasmus MC – Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rianne Oostenbrink
- Department of General Pediatrics, Erasmus MC – Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marjolein Y. Berger
- Department of General Practice, University Groningen, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
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15
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Smits M, Keizer E, Huibers L, Giesen P. GPs' experiences with out-of-hours GP cooperatives: a survey study from the Netherlands. Eur J Gen Pract 2013; 20:196-201. [PMID: 24160262 DOI: 10.3109/13814788.2013.839652] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Out-of-hours primary care has been provided by general practitioner (GP) cooperatives since the year 2000 in the Netherlands. Early studies in countries with similar organizational structures showed positive GP experiences. However, nowadays it is said that GPs experience a high workload at the cooperative and that they outsource a considerable part of their shifts. OBJECTIVES To examine positive and negative experiences of GPs providing out-of-hours primary care, and the frequency and reasons for outsourcing shifts. METHODS A cross-sectional observational survey among 688 GPs connected to six GP cooperatives in the Netherlands, using a web-based questionnaire. RESULTS The response was 55% (n = 378). The main reasons for working in GP cooperatives were to retain registration as GP (79%) and remain experienced in acute care (74%). GPs considered the peak hours (81%) and the high number of patients (73%) as the most negative aspects. Most GPs chose to provide the out-of-hours shifts themselves: 85% outsourced maximally 25% of their shifts. The percentage of outsourced shifts increased with age. Main reasons for outsourcing were the desire to have more private time (76%); the high workload in daytime practice (71%); and less the workload during out-of-hours (46%). CONCLUSION GPs are motivated to work in out-of-hours GP cooperatives, and they outsource few shifts. GPs consider the peak load and the large number of (non-urgent) help requests as the most negative aspects. To motivate and involve GPs for 7 × 24-h primary care, it is important to set limits on their workload.
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Affiliation(s)
- Marleen Smits
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre , Nijmegen , The Netherlands
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Elshout G, van Ierland Y, Bohnen AM, de Wilde M, Oostenbrink R, Moll HA, Berger MY. Alarm signs and antibiotic prescription in febrile children in primary care: an observational cohort study. Br J Gen Pract 2013; 63:e437-44. [PMID: 23834880 PMCID: PMC3693800 DOI: 10.3399/bjgp13x669158] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/29/2012] [Accepted: 02/05/2013] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Although fever in children is often self-limiting, antibiotics are frequently prescribed for febrile illnesses. GPs may consider treating serious infections by prescribing antibiotics. AIM To examine whether alarm signs and/or symptoms for serious infections are related to antibiotic prescription in febrile children in primary care. DESIGN AND SETTING Observational cohort study involving five GP out-of-hours services. METHOD Clinical information was registered and manually recoded. Children (<16 years) with fever having a face-to-face contact with a GP were included. Children who were already using antibiotics or referred to secondary care were excluded. The relation between alarm signs and/or symptoms for serious infections and antibiotic prescription was tested using multivariate logistic regression. RESULTS Of the 8676 included patients (median age 2.4 years), antibiotics were prescribed in 3167 contacts (36.5%). Patient characteristics and alarm signs and/or symptoms positively related to antibiotic prescription were: increasing age (odds ratio [OR] = 1.03; 95% confidence interval [95% CI] = 1.02 to 1.05), temperature measured by GP (OR = 1.72; 95% CI = 1.59 to 1.86), ill appearance (OR = 3.93; 95% CI = 2.85 to 5.42), being inconsolable (OR = 2.27; 95% CI = 1.58 to 3.22), shortness of breath (OR = 2.58; 95% CI = 1.88 to 3.56), duration of fever (OR = 1.31; 95% CI = 1.26 to 1.35). Negative associations were found for neurological signs (OR = 0.45; 95% CI = 0.27 to 0.76), signs of urinary tract infection (OR = 0.63; 95% CI = 0.49 to 0.82), and vomiting and diarrhoea (OR = 0.65; 95% CI = 0.57 to 0.74). These variables explained 19% of the antibiotic prescriptions. CONCLUSION Antibiotics are often prescribed for febrile children. These data suggest that treatment of a supposed serious bacterial infection is a consideration of GPs. However, the relatively low explained variation indicates that other considerations are also involved.
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Affiliation(s)
- Gijs Elshout
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
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Emmett BM, Dovey SM, Wheeler BJ. After-hours on-call: the effect on paediatricians' spouses and families. J Paediatr Child Health 2013; 49:246-50. [PMID: 23414341 DOI: 10.1111/jpc.12108] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2012] [Indexed: 11/25/2022]
Abstract
AIM The after-hours or on-call component of a paediatrician's work has implications for their spouse and family. Little is known about the specifics and extent of this impact. We aimed to understand the potential positive and negative impacts of this important aspect of a paediatrician's work. METHODS The spouses (nine female and one male) of 10 practising paediatricians, who are providing care in a variety of hospital settings within New Zealand, were interviewed using an open-questioning technique. Interviews were analysed by a qualitative line-by-line thematic method in order to categorise the perceived impact of their spouses' on-call work on themselves and their families. RESULTS Participants reported multiple effects of after-hours on-call on themselves, their paediatrician partners and their families. Negative themes included sleep deprivation, restrictions on life-style and living location (specifically home proximity to hospital), spousal sacrifice, intimacy and communication challenges, and diminished quality time with children. Positive themes highlighted professional rewards, financial security and adaptability. Themes were consistent across age, length of relationship, spousal occupation and the presence of children. The intensity of these impacts for our participants appeared to vary depending on the degree of marital support and frequency of on-call. CONCLUSION After-hours on-call has a generally negative impact on paediatricians' spouses and families.
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Affiliation(s)
- Brierley M Emmett
- Department of Women's and Child Health, University of Otago, Dunedin, New Zealand
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Smits M, Huibers L, Oude Bos A, Giesen P. Patient satisfaction with out-of-hours GP cooperatives: a longitudinal study. Scand J Prim Health Care 2012; 30:206-13. [PMID: 23113756 PMCID: PMC3520414 DOI: 10.3109/02813432.2012.735553] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE For over a decade, out-of-hours primary care in the Netherlands has been provided by general practitioner (GP) cooperatives. In the past years, quality improvements have been made and patients have become acquainted with the service. This may have increased patient satisfaction. The objective of this study was to examine changes in patient satisfaction with GP cooperatives over time. DESIGN Longitudinal observational study. A validated patient satisfaction questionnaire was distributed in 2003-2004 (T1) and 2007-2008 (T2). Items were rated on a scale from 0 to 10 (1 = very bad; 10 = excellent). SETTING Eight GP cooperatives in the Netherlands. SUBJECTS Stratified sample of 9600 patients. Response was 55% at T1 (n = 2634) and 51% at T2 (n = 2462). MAIN OUTCOME MEASURES Expectations met; satisfaction with triage nurses, GPs, and organization. RESULTS For most patients the care received at the GP cooperative met their expectations (T1: 86.1% and T2: 88.4%). Patients were satisfied with the triage nurses (overall grade T1: 7.73 and T2: 7.99), GPs (T1: 8.04 and T2: 8.25), and organization (overall grade T1: 7.60 and T2: 7.78). Satisfaction with triage nurses showed the largest increase over time. The quality and effectiveness of advice or treatment were given relatively low grades. Of all organizational aspects, the lowest grades were given for waiting times and information about the cooperative. CONCLUSION In general, patients were initially satisfied with GP cooperatives and satisfaction had even increased four years later. However, there is room for improvement in the content of the advice, waiting times, and information supply. More research is needed into satisfaction of specific patient groups.
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Affiliation(s)
- Marleen Smits
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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van Ierland Y, Seiger N, van Veen M, van Meurs AHJ, Ruige M, Oostenbrink R, Moll HA. Self-referral and serious illness in children with fever. Pediatrics 2012; 129:e643-51. [PMID: 22371470 DOI: 10.1542/peds.2011-1952] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal of this study was to evaluate parents' capability to assess their febrile child's severity of illness and decision to present to the emergency department. We compared children referred by a general practitioner (GP) with those self-referred on the basis of illness-severity markers. METHODS This was a cross-sectional observational study conducted at the emergency departments of a university and a teaching hospital. GP-referred or self-referred children with fever (aged <16 years) who presented to the emergency department (2006-2008) were included. Markers for severity of illness were urgency according to the Manchester Triage System, diagnostic interventions, therapeutic interventions, and follow-up. Associations between markers and referral type were assessed by using logistic regression analysis. Subgroup analyses were performed for patients with the most common presenting problems that accompanied the fever (ie, dyspnea, gastrointestinal complaints, neurologic symptoms, fever without specific symptoms). RESULTS Thirty-eight percent of 4609 children were referred by their GP and 62% were self-referred. GP-referred children were classified as high urgency (immediate/very urgent categories) in 46% of the cases and self-referrals in 45%. Forty-three percent of GP referrals versus 27% of self-referrals needed extensive diagnostic intervention, intravenous medication/aerosol treatment, hospitalization, or a combination of these (odds ratio: 2.0 [95% confidence interval: 1.75-2.27]). In all subgroups, high urgency was not associated with referral type. GP-referred and self-referred children with dyspnea had similar frequencies of illness-severity markers. CONCLUSIONS Although febrile self-referred children were less severely ill than GP-referred children, many parents properly judged and acted on the severity of their child's illness. To avoid delayed or missed diagnoses, recommendations regarding interventions that would discourage self-referral to the emergency department should be reconsidered.
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Affiliation(s)
- Yvette van Ierland
- Department of General Pediatrics, Erasmus MC/Sophia Children’s Hospital, Rotterdam, Netherlands.
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A systematic review of the impact of afterhours care models on emergency departments, ambulance and general practice services. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.aenj.2011.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Taubert M, Nelson A. Heartsink encounters: a qualitative study of end-of-life care in out-of-hours general practice. JRSM SHORT REPORTS 2011; 2:70. [PMID: 21969881 PMCID: PMC3184011 DOI: 10.1258/shorts.2011.011020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives We aimed to establish how prepared GPs who work regular out-of-hours shifts feel when dealing with end-of-life issues in palliative care patients, what they thought about seeing such patients and whether they considered themselves emotionally equipped to do so. Design Semi-structured interviews were conducted with GPs who worked regular out-of-hours shifts. A detailed analysis of transcripts using Interpretative Phenomenological Analysis was undertaken. Setting South Wales. Participants GPs employed by the local health board's out-of-hours service were contacted. Main outcome measures All interview data were analysed systematically and statements that reflected emotional impact and strain were highlighted, coded and interpreted within their context. Results GPs expressed unease and used terms such as ‘heartsink’, when having to deal with palliative care issues out-of-hours. Heartsink in this context referred to the subjective experience of the clinician. Emotional ‘housekeeping’, i.e. looking after oneself after emotionally-charged encounters, was felt to be a very important process and GPs used a range of coping mechanisms, including reflective time, sharing with peers, compartmentalisation and personal empathy to deal with stress. Conclusion The emotional effects of palliative care encounters on out-of-hours GPs should not be underestimated. Our interpretation distinguished the term ‘heartsink’ from its usual context, the ‘heartsink patient’, to a different meaning, that of the imminent palliative care encounter triggering a sensation of heartsink for some out-of-hours doctors. Therefore, the term ‘heartsink encounter’, rather than heartsink patient, seemed more fitting. Pressed services may encourage a culture where discussion or debrief with a colleague after a palliative care encounter is not perceived as a practical option. This may contribute to work-related burnout in this group of doctors and out-of-hours collaboratives need to be aware of this issue, when planning their services.
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Affiliation(s)
- Mark Taubert
- Marie Curie Centre Penarth and Palliative Care Department, Cardiff University, Velindre Hospital , Cardiff CF14 2TL , UK
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22
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Huibers LAMJ, Moth G, Bondevik GT, Kersnik J, Huber CA, Christensen MB, Leutgeb R, Casado AM, Remmen R, Wensing M. Diagnostic scope in out-of-hours primary care services in eight European countries: an observational study. BMC FAMILY PRACTICE 2011; 12:30. [PMID: 21569483 PMCID: PMC3114765 DOI: 10.1186/1471-2296-12-30] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 05/13/2011] [Indexed: 11/17/2022]
Abstract
Background In previous years, out- of-hours primary care has been organised in large-scale organisations in many countries. This may have lowered the threshold for many patients to present health problems at nights and during the weekend. Comparisons of out-of-hours care between countries require internationally comparable figures on symptoms and diagnoses, which were not available. This study aimed to describe the symptoms and diagnoses in out-of-hours primary care services in regions in eight European countries. Methods We conducted a retrospective observational study based on medical records from out-of-hours primary care services in Belgium, Denmark, Germany, the Netherlands, Norway, Slovenia, Spain, and Switzerland. We aimed to include data on 1000 initial contacts from up to three organisations per country. Excluded were contacts with an administrative reason. The International Classification for Primary Care (ICPC) was used to categorise symptoms and diagnoses. In two countries (Slovenia and Spain) ICD10 codes were translated into ICPC codes. Results The age distribution of patients showed a high consistency across countries, while the percentage of males varied from 33.7% to 48.3%. The ICPC categories that were used most frequently concerned: chapter A 'general and unspecified symptoms' (mean 13.2%), chapter R 'respiratory' (mean 20.4%), chapter L 'musculoskeletal' (mean 15.0%), chapter S 'skin' (mean 12.5%), and chapter D 'digestive' (mean 11.6%). So, relatively high numbers of patients presenting with infectious diseases or acute pain related syndromes. This was largely consistent across age groups, but in some age groups chapter H ('ear problems'), chapter L ('musculoskeletal') and chapter K ('cardiovascular') were frequently used. Acute life-threatening problems had a low incidence. Conclusions This international study suggested a highly similar diagnostic scope in out-of-hours primary care services. The incidence rates of acute life-threatening health problems were low in all countries.
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Affiliation(s)
- Linda A M J Huibers
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, PO Box 9101, 114 IQ healthcare, 6500 HB Nijmegen, The Netherlands.
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Chmiel C, Huber CA, Rosemann T, Zoller M, Eichler K, Sidler P, Senn O. Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison. BMC Health Serv Res 2011; 11:94. [PMID: 21554685 PMCID: PMC3123178 DOI: 10.1186/1472-6963-11-94] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 05/09/2011] [Indexed: 11/19/2022] Open
Abstract
Background Emergency Departments (ED) in Switzerland are faced with increasing numbers of patients seeking non-urgent treatment. The high rate of walks-ins with conditions that may be treated in primary care has led to suggestions that those patients would best cared for in a community setting rather than in a hospital. Efficient reorganisation of emergency care tailored to patients needs requires information on the patient populations using the various emergency services currently available. The aim of this study is to evaluate the differences between the characteristics of walk-in patients seeking treatment at an ED and those of patients who use traditional out-of-hours GP (General Practitioner) services provided by a GP-Cooperative (GP-C). Methods In 2007 and 2009 data was collected covering all consecutive patient-doctor encounters at the ED of a hospital and all those occurring as a result of contacting a GP-C over two evaluation periods of one month each. Comparison was made between a GP-C and the ED of the Waid City Hospital in Zurich. Patient characteristics, time and source of referral, diagnostic interventions and mode of discharge were evaluated. Medical problems were classified according to the International Classification of Primary Care (ICPC-2). Patient characteristics were compared using non-parametric tests and multiple logistic regression analysis was applied to investigate independent determinants for contacting a GP-C or an ED. Results Overall a total of 2974 patient encounters were recorded. 1901 encounters were walk-ins and underwent further analysis (ED 1133, GP-C 768). Patients consulting the GP-C were significantly older (58.9 vs. 43.8 years), more often female (63.5 vs. 46.9%) and presented with non-injury related medical problems (93 vs. 55.6%) in comparison with patients at the ED. Independent determining factors for ED consultation were injury, male gender and younger age. Walk-in distribution in both settings was equal over a period of 24 hours and most common during daytime hours (65%). Outpatient care was predominant in both settings but significantly more so at the GP-C (79.9 vs. 85.7%). Conclusions We observed substantial differences between the two emergency settings in a non gate-keeping health care system. Knowledge of the distribution of diagnoses, their therapy, of diagnostic measures and of the factors which determine the patients' choice of the ED or the GP-C is essential for the efficient allocation of resources and the reduction of costs.
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Affiliation(s)
- Corinne Chmiel
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland.
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Schweitzer BPM, Blankenstein N, Deliens L, van der Horst H. Out-of-hours palliative care provided by GP co-operatives: availability, content and effect of transferred information. BMC Palliat Care 2009; 8:17. [PMID: 19943956 PMCID: PMC2789043 DOI: 10.1186/1472-684x-8-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 11/28/2009] [Indexed: 11/26/2022] Open
Abstract
Background Out-of-hours GP care in England, Denmark and the Netherlands has been reorganised and is now provided by large scale GP co-operatives. Adequate transfer of information is necessary in order to assure continuity of care, which is of major importance in palliative care. We conducted a study to assess the availability, content and effect of information transferred to the GP co-operatives. Methods Cross-sectional exploratory study of all palliative care phone calls during a period of one year to a GP co-operative. Results The total number of phone calls about patients who needed palliative care was 0.75% of all calls to the GP co-operative. Information was transferred by GPs on 25.5% of palliative care patient calls, and on 12% of palliative care patient calls from residential care homes. For terminally ill patients the number of information transfers increased to 28.9%. When information was transferred, the content consisted mainly of clinical data. Information about the diagnosis and current problems was transferred in more than 90% of cases, information about the patient's wishes in 45% and information about the patient's psychosocial situation in 30.5% of cases. A home visit was made after 53% of the palliative care calls. When information was transferred, fewer patients were referred to a hospital. Conclusion GPs frequently fail to transfer information about their palliative care patients to the GP co-operatives. Locums working at the GP co-operative are thus required to provide palliative care in complex situations without receiving adequate information GPs should be encouraged and trained to make this information available to the GP co-operatives.
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Affiliation(s)
- Bart P M Schweitzer
- Department of General Practice, and EMGO+Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.
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Fry MM. Barriers and facilitators for successful after hours care model implementation: Reducing ED utilisation. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.aenj.2009.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wong WB, Edgar G, Liddy C, Vaillancourt C. Can after-hours family medicine clinics represent an alternative to emergency departments? Survey of ambulatory patients seeking after-hours care. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2009; 55:1106-1107.e4. [PMID: 19910600 PMCID: PMC2776805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To explore patients' motivations for seeking care in the emergency department (ED) after hours and their willingness to consult their family physicians instead, if their family physicians had been available. DESIGN Survey using an 8-item questionnaire. SETTING Two tertiary care hospital EDs in Ottawa, Ont, from June 4 to 22, 2007, between 5 pm and 9 pm. PARTICIPANTS A total of 151 ambulatory patients. Patients who arrived by ambulance or who bypassed those waiting were excluded. MAIN OUTCOME MEASURES Patients' self-reported motivation for seeking after-hours care in the ED, the perceived urgency of their medical complaints, and their willingness to have sought care from their family physicians instead, if they had been available. RESULTS There were 218 eligible patients during the study period. Among the 151 respondents (69.3% response rate), 141 qualified for the study. Of the qualified respondents, 57.4% would have chosen to consult their family physicians instead if they had been available. The most common reason for choosing the ED was the perceived need for services unavailable at family medicine clinics, such as specialist consultation or diagnostic imaging. There were no differences in the perceived urgency of patients' medical conditions or the amount of time they were willing to wait before physician assessment between those who would have been willing to seek care from their family physicians and those who would not have been willing. CONCLUSION After-hour family medicine clinics provide a desirable primary care service that most patients would choose over the ED if more were available.
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Sentinel monitoring of activity of out-of-hours services in Norway in 2007: an observational study. BMC Health Serv Res 2009; 9:123. [PMID: 19624832 PMCID: PMC2720960 DOI: 10.1186/1472-6963-9-123] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 07/22/2009] [Indexed: 11/24/2022] Open
Abstract
Background In Norway, no valid activity statistics from the primary health care out-of-hours services or the pre-hospital emergency health care system have previously been available. Methods The National Centre for Emergency Primary Health Care has initiated an enterprise called "The Watchtowers" which consists of a representative sample of seven casualty clinics covering 18 Norwegian municipalities. The purpose of the project is to provide routine information over several years, which will enable monitoring, evaluation and comparison of the activities in the out-of-hours services. This paper presents data from 2007, the first full calendar year for the Watchtowers, analyzes some differences in user patterns for the seven casualty clinics involved, and estimates national figures for the use of casualty clinics and out-of-hours services in Norway. Results A total of 85 288 contacts were recorded during 2007 [399 per 1 000 inhabitants] of which 64 846 contacts were considered non-urgent [76.6%]. There were 53 467 consultations by a doctor [250 per 1 000], 8 073 telephone consultations by doctor [38 per 1 000], 2 783 home visits and call-outs by doctor [13 per 1000] and 20 502 contacts managed by nurses on their own [96 per 1000]. The most common mode of contact was by telephone. Women, young children and elderly had the highest rates of contact. Conclusion Norway has a high rate of contacts to the out-of-hours services compared with some other countries with available data. Valid national figures and future research of these services are important both for local services and policy makers.
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Boerma WGW, Groenewegen PP. GP home visiting in 18 European countries Adding the role of health system features. Eur J Gen Pract 2009. [DOI: 10.3109/13814780109094331] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in western countries: assessment of different organizational models. BMC Health Serv Res 2009; 9:105. [PMID: 19549325 PMCID: PMC2717955 DOI: 10.1186/1472-6963-9-105] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 06/23/2009] [Indexed: 11/30/2022] Open
Abstract
Background Internationally, different organizational models are used for providing out-of-hours care. The aim of this study was to assess prevailing models in order to identify their potential strengths and weaknesses. Methods An international web-based survey was done in 2007 in a sample of purposefully selected key informants from 25 western countries. The questions concerned prevailing organizational models for out-of-hours care, the most dominant model in each country, perceived weaknesses, and national plans for changes in out-of-hours care. Results A total of 71 key informants from 25 countries provided answers. In most countries several different models existed alongside each other. The Accident and Emergency department was the organizational model most frequently used. Perceived weaknesses of this model concerned the coordination and continuity of care, its efficiency and accessibility. In about a third of the countries, the rota group was the most dominant organizational model for out-of-hours care. A perceived weakness of this model was lowered job satisfaction of physicians. The GP cooperative existed in a majority of the participating countries; no weaknesses were mentioned with respect to this model. Most of the countries had plans to change the out-of-hours care, mainly toward large scale organizations. Conclusion GP cooperatives combine size of scale advantages with organizational features of strong primary care, such as high accessibility, continuity and coordination of care. While specific patients require other organizational models, the co-existence of different organizational models for out-of-hours care in a country may be less efficient for health systems.
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Affiliation(s)
- Linda Huibers
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, 6500 HB Nijmegen, The Netherlands.
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Margas G, Windak A, Tomasik T. Utilization of the out of hours service in Poland: an observational study from Krakow. BMC Health Serv Res 2008; 8:212. [PMID: 18854013 PMCID: PMC2580764 DOI: 10.1186/1472-6963-8-212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 10/14/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2000 a new GP contract was introduced in Poland. It allowed GPs to subcontract out of hours care to specialized deputizing services. One such service in Kraków provides care to 61 GP practices with a population of 420,000 inhabitants. The aim of this study is to analyze seasonal and geographical variation in out of hours care use and to find the most important factors influencing it. METHODS Routinely collected data for 24 months (2003-2004) containing type, date and time of the contacts were used. RESULTS During the study period 238,072 contacts were recorded: 149,911 ambulatory doctor visits, 23,434 home visits and 64,727 nurse procedures. The mean rate of out of hours contacts was: for ambulatory visits 178 per 1000 inhabitants/year (varied between practices from 9 to 696), for home visits 28 (from 1 to 36) and for nurse procedures 77 (from 3 to 327). The highest rate of ambulatory visits was 739 in the age group 0-4, the lowest - 104 in the age group 45-49. The highest rate of home visits was 221 in the age group over 85. The rate of ambulatory GP visits and nurse procedures was negatively correlated with the distance between the location of GP practice and the nearest out of hours clinic. The rate of home visits was positively correlated with the age of the patient. CONCLUSION Significant differences between practices suggest that non medical factors may play an important role in the patient's decision to see a GP when the surgery is closed. Their influence should be limited to make the system more efficient.
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Affiliation(s)
- Grzegorz Margas
- Chair of Internal Medicine and Gerontology, Jagiellonian University, Medical College, Poland.
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Magin PJ, Adams J, Sibbritt DW, Joy E, Ireland MC. Effects of occupational violence on Australian general practitioners' provision of home visits and after-hours care: a cross-sectional study. J Eval Clin Pract 2008; 14:336-42. [PMID: 18324940 DOI: 10.1111/j.1365-2753.2007.00864.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Occupational violence is increasingly recognized as a problem in general practice, and has been suggested as adversely affecting general practitioners' (GPs) provision of services to patients. The aim of this study was to investigate the association of experiences of violence and perceptions of risk of violence with provision of after-hours GP care and home visits. METHOD A questionnaire-based cross-sectional survey of GPs in three Australian Urban Divisions of General Practice was used. RESULTS Five hundred and twenty-eight GPs completed the survey (response rate 49%). Of the GPs surveyed, 63.7% were subjected to some form of violence in the previous 12 months. Risk of violence influenced 10.2% of GPs' delivery of in-hours home visits and 22.0% of GPs' delivery of after-hours home visits. A further 4.7% of GPs reported not performing after-hours home visits at all during the previous 12 months because of safety concerns. On logistic regression, gender, location of practice and country of medical qualification were significantly associated with provision of in-hours and after-hours home visits. Experience of violence during the previous 12 months was not significantly associated with provision of home visits. CONCLUSIONS This study's finding of GPs' self-reported restriction of practice and withdrawal from home visits and after-hours calls in response to risk of violence represents a significant primary health care issue. GPs' decision to provide after-hours calls and home visits is complex, and the finding of lack of significant association of experiences of violence with provision of home visits and after-hours calls is likely to be due to the cross-sectional nature of the study.
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Affiliation(s)
- Parker J Magin
- Discipline of General Practice, University of Newcastle, Newcastle, NSW, Australia.
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Peconi J, Snooks H, Edwards A. Thematic Research network for emergency and UnScheduled Treatment (TRUST): scoping the potential. BMC Emerg Med 2008; 8:2. [PMID: 18234098 PMCID: PMC2265296 DOI: 10.1186/1471-227x-8-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 01/30/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To identify the benefits of a network in emergency and unscheduled care research, a six week scoping study was undertaken. Objectives were to: draw together stakeholders; identify and prioritise research topics; identify sites for recruitment to studies; and agree a research strategy for a network. METHODS A workshop was held to discuss and agree a research strategy based on results from four activities: visits to established research centres in emergency and unscheduled care; a literature overview; interviews with stakeholders in a GP out-of-hours service; and an exploration of the potential for routine data to support research in emergency care. RESULTS Participants attended the workshop from user groups, primary care, the ambulance service, social care, the national telephone based health helpline, the Welsh Assembly Government and the academic sector. Site visits identified opportunities for collaboration. Gaps in knowledge were identified concerning the effectiveness of alternative models of emergency care delivery. Interview data highlighted a lack of evidence related to the quality of out-of-hours provision of primary care. The All Wales Injury Surveillance System (AWISS) was found to offer the potential to use routine data to support quantitative studies in emergency care. Three key issues emerged across all activities: working across boundaries; patient involvement; and triage. CONCLUSION The study included views from patient, provider, policy and academic perspectives and built the case for a research network in emergency care. Now funded, TRUST (Thematic Research network for emergency and UnScheduled Treatment) will allow the development of research proposals, building of research teams and recruitment of sites and patients both in Wales and across the UK. It aims to address the imbalance between investment and research in this area and help support provision of 'the right care to the right people at the right time'.
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Affiliation(s)
- Julie Peconi
- Centre for Health Information, Research and Evaluation (CHIRAL) School of Medicine, Swansea University, Singleton Park, Swansea, Wales, SA2 8PP, UK
| | - Helen Snooks
- Centre for Health Information, Research and Evaluation (CHIRAL) School of Medicine, Swansea University, Singleton Park, Swansea, Wales, SA2 8PP, UK
| | - Adrian Edwards
- Professor Adrian Edwards, Department of General Practice, Centre for Health Science Research, University Hospital of Wales, Wales, CF14 4YS, UK
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Dunt D, Wilson R, Day SE, Kelaher M, Gurrin L. Impact of telephone triage on emergency after hours GP Medicare usage: a time-series analysis. AUSTRALIA AND NEW ZEALAND HEALTH POLICY 2007; 4:21. [PMID: 17927836 PMCID: PMC2151763 DOI: 10.1186/1743-8462-4-21] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2006] [Accepted: 10/10/2007] [Indexed: 11/18/2022]
Abstract
Background The Australian government sponsored trials aimed at addressing problems in after hours primary medical care service use in five different parts of the country with different after hours care problems. The study's objective was to determine in four of the five trials where telephone triage was the sole innovation, if there was a reduction in emergency GP after hours service utilization (GP first call-out) as measured in Medicare Benefits Schedule claim data. Monthly MBS claim data in both the pre-trial and trial periods was monitored over a 3-year period in each trial area as well as in a national sample outside the trial areas (National comparator). Poisson regression analysis was used in analysis. Results There was significant reduction in first call out MBS claims in three of the four study areas where stand-alone call centre services existed. These were the Statewide Call Centre in both its Metropolitan and Non-metropolitan areas in which it operated – Relative Risk (RR) = 0.87 (95% Confidence interval: 0.86 – 0.88) and 0.60 (95% CI: 0.54 – 0.68) respectively. There was also a reduction in the Regional Call Centre in the non-Metropolitan area in which it operated (RR = 0.46 (95% CI: 0.35 – 0.61) though a small increase in its Metropolitan area (RR = 1.11 (95% CI: 1.06 – 1.17). For the two telephone triage services embedded in existing organisations, there was also a significant reduction for the Deputising Service – RR = 0.62 (95% CI: 0.61 – 0.64) but no change in the Local Triage centre area. Conclusion The four telephone triage services were associated with reduced GP MBS claims for first callout after hours care in most study areas. It is possible that other factors could be responsible for some of this reduction, for example, MBS submitted claims for after hours GP services being reclassified from 'after hours' to 'in hours'. The goals of stand-alone call centres which are aimed principally at meeting population needs rather than managing demand may be being met only in part.
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Affiliation(s)
- David Dunt
- Centre for Health Policy, Programs and Economics, School of Population Health, University of Melbourne, 3010 Vic Australia.
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Moll van Charante EP, van Steenwijk-Opdam PCE, Bindels PJE. Out-of-hours demand for GP care and emergency services: patients' choices and referrals by general practitioners and ambulance services. BMC FAMILY PRACTICE 2007; 8:46. [PMID: 17672915 PMCID: PMC2082275 DOI: 10.1186/1471-2296-8-46] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Accepted: 08/01/2007] [Indexed: 11/29/2022]
Abstract
Background Over the last five years, Dutch provision of out-of-hours primary health care has shifted from practice-based services towards large-scale general practitioner (GP) cooperatives. Only few population-based studies have been performed to assess the out-of-hours demand for GP and emergency care, including the referral patterns to the Accident and Emergency Department (AED) by GPs and ambulance services. Method During two four-month periods (five-year interval), a prospective cross-sectional study was performed for a Dutch population of 62,000 people. Data were collected on all patient contacts with one GP cooperative and three AEDs bordering the region. Results Overall, GPs handled 88% of all out-of-hours contacts (275/1000 inhabitants/year), while the AED dealt with the remaining 12% of contacts (38/1000 inhabitants/year). Within the AED, the self-referrals represented a substantial number of contacts (43%), although within the total out-of-hours demand they only represented 5% of all contacts. Self-referrals were predominantly young adult males presenting with an injury, nineteen percent of whom had a fracture. Compared to self-referrals, patients who were referred by the GP or brought in by the ambulance services were generally older and were more frequently admitted for both injury and non-injury (p < 0.01 for all differences). Conclusion The GP cooperative deals with the large majority of out-of-hours problems presented. Within the total demand, self-referrals constitute a stable, yet small group of patients, many of whom seem to have made a reasonable choice to attend the AED. The GPs and the ambulance services appear to be effectively selecting the problems that are presented to the AED.
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Affiliation(s)
- Eric P Moll van Charante
- Department of General Practice, Academic Medical Centre, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
| | | | - Patrick JE Bindels
- Department of General Practice, Academic Medical Centre, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
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Lordan G. What determines a patient’s treatment? Evidence from out of hours primary care co-op data in the Republic of Ireland. Health Care Manag Sci 2007; 10:283-92. [PMID: 17695138 DOI: 10.1007/s10729-007-9020-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study explores consistency in healthcare. It investigates whether vulnerable groups in the population receive the most appropriate care. This is achieved by considering the case study of individuals who present to out of hours (OOH) primary care services in the Republic of Ireland with gastroenteritis. Specifically an individual can potentially receive four services; nurse advice, doctor advice, a treatment centre consultation or a home visit. Results show that service choice is influenced by patient, call and seasonal characteristics to varying degrees. Patient symptoms are the primary driver of the type of service the patients receives. Results also indicate that the OOH primary care facilities individual characteristics do not affect service choice. This suggests a degree of consistent care across these organisations. It also provides evidence that service choice is exogenous to the organisation.
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Affiliation(s)
- Grace Lordan
- Department of Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin 2, Ireland.
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Giesen P, Moll van Charante E, Mokkink H, Bindels P, van den Bosch W, Grol R. Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: determinants of a negative evaluation. PATIENT EDUCATION AND COUNSELING 2007; 65:131-6. [PMID: 16939708 DOI: 10.1016/j.pec.2006.06.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 06/27/2006] [Accepted: 06/29/2006] [Indexed: 05/11/2023]
Abstract
OBJECTIVE The shift towards large-scale organization of out-of-hours primary healthcare in different western countries has created an important role for the nurse telephone consultation. We explored the association between negative patient evaluation of nurse telephone consultations and characteristics of patients and GP cooperatives. METHODS A cross-sectional study using postal patient questionnaires sent to patients receiving a nurse telephone consultation from one of 26 GP cooperatives in the Netherlands. RESULTS The total response was 49.3% (2583/5239). Negative evaluations were most frequently encountered for the general information received on the GP cooperative (35%). When patients expected a centre consultation or home visit, but only received a nurse telephone consultation, they were more negative about the accessibility (OR 1.7, CI 1.4-2.1) and nurse telephone consultation (OR 4.2, CI 3.2-5.6). In the presence of a special supervising telephone doctor at the cooperative's call centre, nurse telephone consultation was evaluated significantly less negative (OR 0.4, CI 0.2-0.8). CONCLUSION Expectation of care mode was most strongly associated with a negative evaluation of nurse telephone consultation. The presence of a supervising telephone doctor may lead to a better evaluation of nurse telephone consultations. PRACTICE IMPLICATIONS More attention should be paid to the provision of patient information on the GP cooperative and discrepancies between the care expected and the care offered.
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Affiliation(s)
- Paul Giesen
- Centre for Quality-of-Care Research (WOK), Radboud University, Nijmegen Medical Centre, WOK 117, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Peppas G, Theocharis G, Karveli EA, Falagas ME. An analysis of patient house calls in the area of Attica, Greece. BMC Health Serv Res 2006; 6:112. [PMID: 16953873 PMCID: PMC1574301 DOI: 10.1186/1472-6963-6-112] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 09/05/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physicians house calls to patients have been declining in many countries of the world. The objective of this study was to describe the patterns of utilization of house call services provided by SOS doctors in the area of Attica, Greece. METHODS We performed a retrospective analysis of data regarding house call visits of patients in the area of Attica (metropolitan area of Athens and surrounding cities), Greece. Characteristics of patients who received house call services by a physician, including diagnosis, and recommended management plan, including advice for hospitalization were analyzed. RESULTS SOS doctors in the area of Attica, Greece performed 98,009 house calls during the 5-year study period (1/11/2000-31/10/2005). Patients older than 65 years requested 47.8% of the house calls. Females requested more house calls during the studied period compared to males (59.4% versus 40.6%, p < 0.001). The majority of the diagnoses (18.4%) were infections of the upper and lower respiratory tract. 9.1% of patients were advised after the evaluation at home to be admitted to a hospital to receive inpatient services. CONCLUSION Our analysis documents the utilization of house calls by SOS doctors in the area of Attica, Greece during a 5-year period. We believe that house calls provided by individual practitioners, physician group practices, or organized companies and organizations should re-gain their well-deserved position in the modern health care systems.
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Affiliation(s)
- George Peppas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece
- SOS doctors, Athens, Greece
| | | | | | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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Farmer J, Iversen L, Campbell NC, Guest C, Chesson R, Deans G, MacDonald J. Rural/urban differences in accounts of patients' initial decisions to consult primary care. Health Place 2006; 12:210-21. [PMID: 16338636 DOI: 10.1016/j.healthplace.2004.11.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2004] [Indexed: 10/25/2022]
Abstract
In the UK, patients in urban areas consult primary health care more than rural patients for both trivial and serious conditions. This study, involving focus groups and interviews, examined rural/urban differences in accounts of patients' intentions around initial decisions to consult general practice. Findings suggest 'relationships' between doctors and patients and easier access to appointments could affect consulting in rural areas, while decision-making for urban patients tended to be more consumerist. Perceptions about access to different health services meant rural patients' decision-making in out-of-hours emergencies was complex. Rural/urban differences in demand could be affected by change in UK primary care provision.
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Affiliation(s)
- Jane Farmer
- University of Aberdeen Business School, Edward Wright Building, Dunbar Street, Old Aberdeen AB24 3QY, UK.
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Hurst K. British out‐of‐hours primary and community care: a review of the literature. Int J Health Care Qual Assur 2006; 19:42-59. [PMID: 16548398 DOI: 10.1108/09526860610642591] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This out-of-hours primary and community care services (more recently called unscheduled care) literature review sets out to build on the foundations set by earlier publications by examining old and fresh issues after the new General Medical Service contract was implemented in 2004. DESIGN/METHODOLOGY/APPROACH Almost 140 publications were located, including a range of theoretical and empirical publications. FINDINGS A total of seven themes emerge--varying from the most frequently discussed (service nature and value) to the least examined (information management and technology). ORIGINALITY/VALUE Analysis not only underlines service problems and tensions noted previously but also generates new insights, which cannot be ignored if services are to be developed. Consequently, several recommendations are made.
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Affiliation(s)
- Keith Hurst
- Nuffield Health and Social Care Policy Group, Health Sciences and Public Health Research Institute, Leeds University, UK.
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Dunt D, Day SE, Kelaher M, Montalto M. Impact of standalone and embedded telephone triage systems on after hours primary medical care service utilisation and mix in Australia. AUSTRALIA AND NEW ZEALAND HEALTH POLICY 2005; 2:30. [PMID: 16343354 PMCID: PMC1334205 DOI: 10.1186/1743-8462-2-30] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Accepted: 12/12/2005] [Indexed: 11/28/2022]
Abstract
Background The Australian government sponsored five local trials aimed at addressing problems in after hours (AH) primary medical care (PMC). The study's objective was to determine if the four trials, where telephone triage was the sole innovation, led to a reduction in AH service utilisation and change in service mix towards AH GP clinics. Changes in utilisation and mix of AH GP clinic and home visits, ED and ambulance use were monitored in the trial areas, and in a national sample to adjust for the effects of secular trend. Pre- and post-trial telephone surveys of two separate random samples of approximately 350 AH PMC user households in each area were conducted. Results Some types of AH PMC use became more frequent in both of the standalone services using nurse-administered proprietary call centre software, which were aimed at better addressing population need (Statewide call centre; Regional call centre). Service use overall (95%CI: 1.03–1.83) and GP clinic use (95%CI: 1.07–2.00) increased in the metro area of the Statewide call centre and in GP clinic (95%CI: 1.04–2.14) and home visits (95%CI: 1.03–3.91) in the non-metro area of the Regional call centre. Service mix only changed in the non-metro area of the Regional call centre with increased contact in GP home visits (95%CI: 1.02–4.38). Levels of use remained unchanged in both embedded services using other than proprietary software, which were established to support the GP workforce (Deputising service; Local triage centre). Service mix only changed in the Deputising service with a change away from AH GP clinics in both contact (95%CI: 0.39–0.97) and frequency (95% CI: -2.12 – -0.7). Conclusion Bearing in mind limitations in estimating AH PMC utilisation levels and mix, it is concluded that the impacts of telephone triage were generally smaller in Australia than reported elsewhere. There were different impacts on levels of service utilisation and service mix in standalone call centres and embedded services. Impacts of telephone triage on service utilisation and mix are influenced by the type of telephone triage offered, the goals of the agency providing the service, as well as local factors. (345 words)
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Affiliation(s)
- David Dunt
- Program Evaluation Unit, School of Population Health, University of Melbourne, 3010, Australia
| | - Susan E Day
- Program Evaluation Unit, School of Population Health, University of Melbourne, 3010, Australia
| | - Margaret Kelaher
- Program Evaluation Unit, School of Population Health, University of Melbourne, 3010, Australia
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van Uden CJT, Winkens RAG, Wesseling G, Fiolet HFBM, van Schayck OCP, Crebolder HFJM. The impact of a primary care physician cooperative on the caseload of an emergency department: the Maastricht integrated out-of-hours service. J Gen Intern Med 2005; 20:612-7. [PMID: 16050847 PMCID: PMC1490166 DOI: 10.1111/j.1525-1497.2005.0091.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the effect of an out-of-hours primary care physician (PCP) cooperative on the caseload at the emergency department (ED) and to study characteristics of patients utilizing out-of-hours care. DESIGN A pre-post intervention design was used. During a 3-week period before and a 3-week period after establishing the PCP cooperative, all patient records with out-of-hours primary and emergency care were analyzed. SETTING Primary care in Maastricht (the Netherlands) is delivered by 59 PCPs. Primary care physicians formerly organized out-of-hours care in small locum groups. In January 2000, out-of-hours primary care was reorganized, and a PCP cooperative was established. This cooperative is located at the ED of the University Hospital Maastricht, the city's only hospital, which has no emergency medicine specialists. MAIN OUTCOME MEASURES The number of patients utilizing out-of-hours care, their age and sex, diagnoses, post-ED care, and serious adverse events. RESULTS After establishing the PCP cooperative, the proportion of patients utilizing emergency care decreased by 53%, and the proportion of patients utilizing primary care increased by 25%. The shift was the largest for patients with musculoskeletal disorders or skin problems. There were fewer hospital admissions, and fewer subsequent referrals to the patient's own PCP and medical specialists. No substantial change in new outpatient visits at the hospital or in mortality occurred. CONCLUSIONS In the city of Maastricht, the Netherlands, the PCP cooperative reduced the use of hospital emergency care during out-of-hours care.
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Affiliation(s)
- Caro J T van Uden
- Department of Integrated Care, Research Institute Caphri, University Hospital Maastricht, Maastricht, The Netherlands.
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Anderson R, Thomas DW, Phillips CJ. The effectiveness of out-of-hours dental services: I. Pain relief and oral health outcome. Br Dent J 2005; 198:91-7; discussion 88. [PMID: 15702108 DOI: 10.1038/sj.bdj.4811979] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2003] [Accepted: 02/03/2004] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the effectiveness of four types of out-of-hours emergency dental service, including both 'walk-in' and telephone-access services. BASIC DESIGN Questionnaire survey of patients attending weekend emergency dental services, with measurement of self-reported oral health status and dental pain (at attendance and follow-up) and retrospective judgements of change in oral health status. SETTING Two health authorities in South Wales, UK. SUBJECTS A total of 783 patients who completed questionnaires at attendance, and 423 who completed follow-up questionnaires. RESULTS For patients who saw a dentist there were no consistent differences in the effectiveness of the four services, whether measured as pain relief, oral health gain or using patients' retrospective transition judgements about feeling better after their episode of emergency dental care. The proportion of patients reporting no improvement (transition judgements), either an hour after or the day after seeing the dentist, was surprisingly high (30-40% and 23-38% respectively). Although the 'rotas for all' - a telephone-access GDP-provided service for both registered and unregistered patients - achieved both the highest reductions in pain scores and the greatest improvements in dental health status between attendance and follow-up, this effect may reflect health gains due to care received after the episode of emergency dental care. CONCLUSIONS Neither the setting where emergency dental patients are seen, nor the type of dentist who sees them, appear to have any significant effect on patient-reported health outcomes. Although further exploration of the factors that predict poor pain relief or low oral health gain is required, future research on these services should focus on the process of care and accessibility.
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Affiliation(s)
- R Anderson
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, PO Box 123, Broadway NSW 2007, Australia.
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Tolhurst HM, Stewart SM. Balancing work, family and other lifestyle aspects: a qualitative study of Australian medical students’ attitudes. Med J Aust 2004; 181:361-4. [PMID: 15462650 DOI: 10.5694/j.1326-5377.2004.tb06326.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2004] [Accepted: 07/29/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the attitudes of Australian medical students to the balance between work, family and other aspects of lifestyle, within a broader exploration of the issues that they regard as important to their decisions about future career. DESIGN Qualitative study using semistructured focus groups and individual interviews. SETTING The three medical schools in New South Wales and a national conference for students interested in rural practice. PARTICIPANTS First- and final-year medical students who volunteered for focus groups held between March and August 2002 (82 students in 10 groups) or for individual interviews held between July and December 2003 (48 students). MAIN OUTCOME MEASURES Emergent themes relating to the balance of work, family and other aspects of lifestyle. RESULTS Most students referred to a balance of work, family and lifestyle as an important factor in their career decisions. While indicating they were committed to medicine, they were unwilling to work to the exclusion of all else. Most saw family commitments as a high priority, and many saw "time out" as important in maintaining their health. Female students spoke of part-time work as essential for future happiness, while some male students expressed a preference for working part-time. They would seek to achieve balance by choosing to work in disciplines, locations and structures where limited-hours work is available, and would negotiate support from their partners and parents in caring for children. CONCLUSIONS It is important that the medical profession continue to develop working and training structures that allow a balance of work, family and lifestyle.
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Affiliation(s)
- Helen M Tolhurst
- Discipline of General Practice, University of Newcastle, Callaghan, NSW, Australia.
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Christensen MB, Christensen B, Mortensen JT, Olesen F. Intervention among frequent attenders of the out-of-hours service: a stratified cluster randomized controlled trial. Scand J Prim Health Care 2004; 22:180-6. [PMID: 15370796 DOI: 10.1080/02813430410006576] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To investigate whether the number of frequent attenders (FA) contacts with the out-of-hours service can be reduced by deploying a combination of intervention strategies. DESIGN A stratified cluster randomized controlled trial, each cluster containing a general practice and all its listed patients. SETTING The out-of-hours service in the county of Northern Jutland (490,000 inhabitants), Denmark. INTERVENTIONS The following intervention strategies were deployed: predisposition, individual instruction, economic incitement, continuing medical education meetings, feedback/reminder, and patient-mediated intervention. SUBJECTS An intervention group of 3500 patients and a control group of 4635 patients. MAIN OUTCOME MEASURES Absolute and relative fall in the number of contacts with the out-of-hours service per patient after 6 and 12 months. RESULTS Analysed by group, intervention patients saw a more pronounced decline in the number of contacts than controls, except for two outcomes. However, this difference was only significant after 12 months. For women aged 17-66 years with 5-9 contacts during the previous 12 months, the decrease was significantly more pronounced in the intervention group for all outcomes (p=0.004-0.042). However, for the rest of the subgroups the effect varied more, and in several cases it was more distinct in the control group. CONCLUSION The data collected point towards an effect of intervention on the use of out-of-hours services even if the responses obtained were not uniform and unequivocal. However, one has to consider the problems of multiple comparisons and in conclusion no convincing effect of the intervention was found.
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Affiliation(s)
- Morten Bondo Christensen
- Research Unit and Department of General Practice, University of Aarhus, DK-8000 Aarhus, Denmark.
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Simpson RG, Graham D, Martin K. Analysis of out of hours telephone consultation at the medical reception station Sennelager, British Forces Germany. J ROY ARMY MED CORPS 2004; 146:28-30. [PMID: 15241981 DOI: 10.1136/jramc-146-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The advent of 'NHS Direct', has centred attention on nurses giving telephone advice as part of the provision of out of hours medical care. A three month retrospective study of telephone consultations by nurses at the MRS Sennelager showed that telephone consultation greatly contributes to "out of hours" medical care. The outcome of telephone consultations made out of hours revealed that in 70% of telephone calls the advice given enables the patient to stay at home. Twenty eight percent of patient contact out of hours was by telephone.
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Gunstone C. Changes in perception of workload. Br J Gen Pract 2004; 54:389-90. [PMID: 15113529 PMCID: PMC1266180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
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Abstract
BACKGROUND A number of previous studies on minor illness have concentrated on nurse-led clinics and the role of nurse practitioners. This study examines the effect of a minor illness education programme which aimed to increase parents' confidence and knowledge in managing childhood illnesses. AIM The primary aim of this study was to evaluate the effectiveness of a home visit and booklet in providing education to parents about minor infant illnesses. DESIGN A randomized controlled trial was conducted. The intervention involved a home visit to discuss parents' concerns and provide advice and information, and a booklet advising parents what to do and when to consult about infant illnesses. METHOD A total of 120 parents of 6 week old babies were identified over a 6 month period, using health visitors' caseloads, and randomized to an intervention group (60), that received a visit and a booklet, or a control group (60) that received standard care. Groups were compared on entry to the study and at 7 months, in terms of parental knowledge and confidence about childhood illnesses, the intended use of home care activities, intention to consult professionals and actual use of health services. Data were collected by self-completed questionnaire and case note review. FINDINGS The educational intervention resulted in a reduction in visits to the child health clinic but had little effect on use of other services. Parents in the intervention group showed a general trend towards greater certainty about the home care options they would choose, and a reduction in intention to consult a doctor. However, they also indicated a feeling of reduced confidence and knowledge. CONCLUSION The trial showed no effect on use of services but did demonstrate reduction in parents' intentions to consult a doctor, which appeared to be because of increased certainty about home care. However, it is of concern that they indicated feeling less confident and knowledgeable. It is not possible to clarify whether this represented anxiety that was constructive, enhancing decision-making or was destructive. Further work into the role of education in parental decision-making, anxiety levels and enhancement of confidence is required.
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Affiliation(s)
- Helen Robbins
- Moray LHC, Grampian Primary Care Trust, King Edward, Banff, UK.
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Labarère J, Torres JP, Francois P, Fourny M, Argento P, Gensburger X, Menthonnex P. Patient compliance with medical advice given by telephone. Am J Emerg Med 2003; 21:288-92. [PMID: 12898484 DOI: 10.1016/s0735-6757(03)00087-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Data on compliance with medical advice given by telephone consultation services are currently lacking. The aim of this study was to assess patient compliance with medical advice given by a call center. A cross-sectional telephone survey was carried out on a random sample of 463 callers 72 hours after contacting the Grenoble Dial 15 center in France. Four hundred nine subjects (88.3%) participated in the study. Of these, 286 callers (69.9%) complied with the medical advice given. Compliance was 61.4% among patients who were advised to treat themselves, 83.9% among patients who were advised to consult a general practitioner during business hours, and 64.0% among patients who were advised to go to an accident and ED (P <.01). The survey pointed out adverse events resulting from the service. Assessing patient compliance can be an important source of information for improving aspects of patient management provided by telephone consultation services.
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Affiliation(s)
- José Labarère
- Medical Evaluation Unit, University Hospital, Pavillon D. Villars, CHU-BP 217, 38 043 Grenoble cedex 9, France.
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van Uden CJT, Winkens RAG, Wesseling GJ, Crebolder HFJM, van Schayck CP. Use of out of hours services: a comparison between two organisations. Emerg Med J 2003; 20:184-7. [PMID: 12642541 PMCID: PMC1726038 DOI: 10.1136/emj.20.2.184] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate differences in numbers and characteristics of patients using primary or emergency care because of differences in organisation of out of hours care. BACKGROUND Increasing numbers of self referrals at the accident and emergency (A&E) department cause overcrowding, while a substantial number of these patients exhibit minor injuries that can be treated by a general practitioner (GP). METHODS Two different organisations of out of hours care in two Dutch cities (Heerlen and Maastricht) were investigated. Important differences between the two organisations are the accessibility and the location of primary care facility (GP cooperative). The Heerlen GP cooperative is situated in the centre of the city and is respectively 5 km and 9 km away from the two A&E departments situated in the area of Heerlen. This GP cooperative can only be visited by appointment. The Maastricht GP cooperative has free access and is located within the local A&E department. During a three week period all registration forms of patient contacts with out of hours care (GP cooperative and A&E department) were collected and with respect to the primary care patients a random sample of one third was analysed. RESULTS For the Heerlen and Maastricht GP cooperative the annual contact rate, as extrapolated from our data, per 1000 inhabitants per year is 238 and 279 respectively (chi(2)((1df))=4.385, p=0.036). The contact rate at the A&E departments of Heerlen (n=66) and Maastricht (n=52) is not different (chi(2)((1df))=1.765, p=0.184). Some 51.7% of the patients attending the A&E department in Heerlen during out of hours were self referred, compared with 15.9% in Maastricht (chi(2)((1df))=203.13, p<0.001). CONCLUSIONS The organisation of out of hours care in Maastricht has optimised the GP's gatekeeper function and thereby led to fewer self referrals at the A&E department, compared with Heerlen.
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Affiliation(s)
- C J T van Uden
- Department of Transmural Care, Research Institute Extra, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, Netherlands.
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Pooley CG, Briggs J, Gatrell T, Mansfield T, Cummings D, Deft J. Contacting your GP when the surgery is closed: issues of location and access. Health Place 2003; 9:23-32. [PMID: 12609470 DOI: 10.1016/s1353-8292(02)00027-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This paper examines spatial variation in the delivery of out of hours care through general practice, in two Health Authorities in northwest England. It demonstrates considerable variations in the type of care provided to patients in different parts of the region. These differences are not due primarily to either the geographical or socio-economic characteristics of the areas. Rather, the type of out of hours care delivered depends much more on variations in the structure and organization of service delivery. These factors, in turn, largely reflect the history of service development in each area and the ethos of individual general practitioners instrumental in establishing the service.
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Affiliation(s)
- Colin G Pooley
- Department of Geography, Lancaster University, LA1 4YB, Lancaster, UK.
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