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Davies F, Edwards M, Price D, Anderson P, Carson-Stevens A, Choudhry M, Cooke M, Dale J, Donaldson L, Evans BA, Harrington B, Harris S, Hepburn J, Hibbert P, Hughes T, Hussain F, Islam S, Pockett R, Porter A, Siriwardena AN, Snooks H, Watkins A, Edwards A, Cooper A. Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-152. [PMID: 38687611 DOI: 10.3310/jwqz5348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Background Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models. Objectives To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models. Design Mixed-methods realist evaluation. Methods Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development. Results General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models. Limitations The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored. Conclusion Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services. Future work The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. Study registration This study is registered as PROSPERO CRD42017069741. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Freya Davies
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Bangor Institute for Health and Medical Research, Bangor University, Wales, UK
| | | | - Mazhar Choudhry
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew Cooke
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | - Jeremy Dale
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | | | - Bridie Angela Evans
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Shaun Harris
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Julie Hepburn
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Faris Hussain
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Saiful Islam
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Rhys Pockett
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Alison Porter
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Helen Snooks
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Alan Watkins
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
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Gille F, Frei A, Kaufmann M, Lehmann A, Muñoz Laguna J, Papadopoulos K, Spörri A, Stanikić M, Tušl M, Zavattaro F, Puhan MA. A guide for a student-led doctoral-level qualitative methods short course in epidemiology: faculty and student perspectives. Int J Epidemiol 2024; 53:dyae029. [PMID: 38389285 PMCID: PMC10883707 DOI: 10.1093/ije/dyae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Qualitative research and mixed methods are core competencies for epidemiologists. In response to the shortage of guidance on graduate course development, we wrote a course development guide aimed at faculty and students designing similar courses in epidemiology curricula. The guide combines established educational theory with faculty and student experiences from a recent introductory course for epidemiology and biostatistics doctoral students at the University of Zurich and Swiss Federal Institute of Technology, Zurich. We propose a student-centred course with inverse classroom teaching and practice exercises with faculty input. Integration of student input during the course development process helps align the course syllabus with student needs. The proposed course comprises six sessions that cover learning outcomes in comprehension, knowledge, application, analysis, synthesis and evaluation. Following an introductory session, the students engage in face-to-face interviews, focus group interviews, observational methods, analysis and how qualitative and quantitative methods are integrated in mixed methods. Furthermore, the course covers interviewer safety, research ethics, quality in qualitative research and a practice session focused on the use of interview hardware, including video and audio recorders. The student-led teaching characteristic of the course allows for an immersive and reflective teaching-learning environment. After implementation of the course and learning from faculty and student perspectives, we propose these additional foci: a student project to apply learned knowledge to a case study; integration in mixed-methods; and providing faculty a larger space to cover theory and field anecdotes.
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Affiliation(s)
- Felix Gille
- Institute for Implementation Science in Health Care (IfIS), University of Zurich, Zurich, Switzerland
- Digital Society Initiative (DSI), University of Zurich, Zurich, Switzerland
| | - Anja Frei
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Marco Kaufmann
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Anja Lehmann
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Javier Muñoz Laguna
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital and University of Zurich, Zurich, Switzerland
| | - Kimon Papadopoulos
- Institute for Implementation Science in Health Care (IfIS), University of Zurich, Zurich, Switzerland
- Digital Society Initiative (DSI), University of Zurich, Zurich, Switzerland
| | - Angela Spörri
- Central Informatics, Multimedia an E-Learning Services, University of Zurich, Zurich, Switzerland
| | - Mina Stanikić
- Institute for Implementation Science in Health Care (IfIS), University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Martin Tušl
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Federica Zavattaro
- Institute for Implementation Science in Health Care (IfIS), University of Zurich, Zurich, Switzerland
- Digital Society Initiative (DSI), University of Zurich, Zurich, Switzerland
| | - Milo Alan Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
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3
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Syafrawati S, Machmud R, Aljunid SM, Semiarty R. Incidence of moral hazards among health care providers in the implementation of social health insurance toward universal health coverage: evidence from rural province hospitals in Indonesia. Front Public Health 2023; 11:1147709. [PMID: 37663851 PMCID: PMC10473252 DOI: 10.3389/fpubh.2023.1147709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Objective To identify the incidence of moral hazards among health care providers and its determinant factors in the implementation of national health insurance in Indonesia. Methods Data were derived from 360 inpatient medical records from six types C public and private hospitals in an Indonesian rural province. These data were accumulated from inpatient medical records from four major disciplines: medicine, surgery, obstetrics and gynecology, and pediatrics. The dependent variable was provider moral hazards, which included indicators of up-coding, readmission, and unnecessary admission. The independent variables are Physicians' characteristics (age, gender, and specialization), coders' characteristics (age, gender, education level, number of training, and length of service), and patients' characteristics (age, birth weight, length of stay, the discharge status, and the severity of patient's illness). We use logistic regression to investigate the determinants of moral hazard. Results We found that the incidences of possible unnecessary admissions, up-coding, and readmissions were 17.8%, 11.9%, and 2.8%, respectively. Senior physicians, medical specialists, coders with shorter lengths of service, and patients with longer lengths of stay had a significant relationship with the incidence of moral hazard. Conclusion Unnecessary admission is the most common form of a provider's moral hazard. The characteristics of physicians and coders significantly contribute to the incidence of moral hazard. Hospitals should implement reward and punishment systems for doctors and coders in order to control moral hazards among the providers.
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Affiliation(s)
| | | | - Syed Mohamed Aljunid
- Department of Community Medicine, School of Medicine, International Medical University, Kuala Lumpur, Malaysia
- International Center for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia, Cheras, Malaysia
| | - Rima Semiarty
- Faculty of Medicine, Andalas University, Padang, Indonesia
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Zhuang Q, Chan JSE, See LKY, Chiang J, Suhaimi SR, Chua TWL, Venkataraman A. Characteristics of unplanned hospitalisations among cancer patients in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:882-891. [PMID: 34985100 DOI: 10.47102/annals-acadmedsg.2021212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Cancer is a pervasive global problem with significant healthcare utilisation and cost. Emergency departments (EDs) see large numbers of patients with oncologic emergencies and act as "gate-keepers" to subsequent hospital admissions. A proportion of such hospital admissions are rapidly discharged within 2 days and may be potentially avoidable. METHODS Over a 6-month period, we conducted a retrospective audit of active cancer patients presenting to the ED with subsequent admission to the Department of Medical Oncology. Our aims were to identify independent factors associated with a length of stay ≤2 days; and characterise the clinical and resource needs of these short admissions. RESULTS Among all medical oncology admissions, 24.4% were discharged within 2 days. Compared to longer stayers, patients with short admissions were significantly younger (P=0.010), had lower National Early Warning Scores (NEWS) (P=0.006), and had a lower proportion of gastrointestinal and hepatobiliary cancers (P=0.005). Among short admissions, common presenting medical problems were infections (n=144, 36.3%), pain (n=116, 29.2%), gastrointestinal complaints (n=85, 21.4%) and respiratory complaints (n=76, 19.1%). These admissions required investigations and treatments already available at the ED. CONCLUSION Short admissions have low resource needs and may be managed in the ED. This may help save valuable inpatient bed-days and reduce overall healthcare costs.
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Affiliation(s)
- Qingyuan Zhuang
- Division of Supportive and Palliative Care, National Cancer Centre, Singapore
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5
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Demarquet M, Fraticelli L, Freyssenge J, Claustre C, Martinez M, Duchenne J, El Khoury C, Redjaline A, Tazarourte K. Discovering the underlying typology of emergency departments. BMC Med Res Methodol 2021; 21:116. [PMID: 34090330 PMCID: PMC8180120 DOI: 10.1186/s12874-021-01305-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/30/2021] [Indexed: 11/15/2022] Open
Abstract
Background We hypothesized that monitoring the volume of activity and overall performance indicators is not sufficient to understand the underlying differences between emergency departments. We aimed to understand the underlying common characteristics of emergency departments and map their typology in order to propose adaptive solutions, that would take into account territorial specificities and manage existing resources. Methods We applied a multifactorial analysis based on input data at three levels; 1) the health care available in the area surrounding the emergency departments, 2) the level of medical technicality of the hospitals and 3) the profile of emergency department visits. Results We included 73 emergency departments in this study, representing 93.6% of the emergency departments in our region and seven groups were retained. The smallest group (n = 5) included both public and private structures with low volumes of activity. These medical structures were associated with the shortest length of stay and one of the lowest hospitalisation rates. The largest group (n = 21) included only public structures in peri-urban areas, which were associated with the highest rate of hospitalization in the region. The surrounding population was representative of the regional population, but the patients were older. Conclusions This approach represents a systemic response to target the organisational needs and constraints, propose appropriate solutions and adjust the financial resources allocated to hospitals. Future policies to improve care delivery may benefit from stratifying solutions and performance objectives depending on these groups. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01305-x.
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Affiliation(s)
- Marine Demarquet
- Centre Hospitalier de Fleyriat, Bourg-en-Bresse, France.,Observatoire Régional Des Urgences (ORU), Agence Régionale de Santé Auvergne Rhône-Alpes, Lyon, France
| | - Laurie Fraticelli
- Observatoire Régional Des Urgences (ORU), Agence Régionale de Santé Auvergne Rhône-Alpes, Lyon, France. .,RESCUe-RESUVal Network, Hospital Center Lucien Hussel, Montée Docteur Maurice Chapuis, 38200, Vienne, France. .,Laboratory Systemic Health Care, EA 4129, University of Lyon 1, Lyon, France.
| | - Julie Freyssenge
- Observatoire Régional Des Urgences (ORU), Agence Régionale de Santé Auvergne Rhône-Alpes, Lyon, France.,RESCUe-RESUVal Network, Hospital Center Lucien Hussel, Montée Docteur Maurice Chapuis, 38200, Vienne, France.,Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
| | - Clément Claustre
- RESCUe-RESUVal Network, Hospital Center Lucien Hussel, Montée Docteur Maurice Chapuis, 38200, Vienne, France
| | - Mikaël Martinez
- Observatoire Régional Des Urgences (ORU), Agence Régionale de Santé Auvergne Rhône-Alpes, Lyon, France.,Centre Hospitalier du Forez, Montbrison, France.,REULIAN Network, Firminy, France
| | - Jonathan Duchenne
- RAMU Network, Aurillac, France.,Centre Hospitalier Henri Mondor, Aurillac, France
| | - Carlos El Khoury
- RESCUe-RESUVal Network, Hospital Center Lucien Hussel, Montée Docteur Maurice Chapuis, 38200, Vienne, France.,Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France.,Emergency Department and Clinical Research Unit, Medipole Hopital Mutualiste, Villeurbanne, France
| | - Abdesslam Redjaline
- Observatoire Régional Des Urgences (ORU), Agence Régionale de Santé Auvergne Rhône-Alpes, Lyon, France.,REULIAN Network, Firminy, France.,Centre Hospitalier Le Corbusier, Firminy, France
| | - Karim Tazarourte
- Observatoire Régional Des Urgences (ORU), Agence Régionale de Santé Auvergne Rhône-Alpes, Lyon, France.,Research On Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France.,Department of Emergency Medicine and SAMU, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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6
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Sy A, Moglia B, Aragunde G, Derossi P. Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services. CAD SAUDE PUBLICA 2021; 37:e00026120. [PMID: 33503159 DOI: 10.1590/0102-311x00026120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022] Open
Abstract
The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.
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Affiliation(s)
- Anahi Sy
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Brenda Moglia
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Gisele Aragunde
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina
| | - Paula Derossi
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina
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Wilson A, Baker R, Bankart J, Banerjee J, Bhamra R, Conroy S, Kurtev S, Phelps K, Regen E, Rogers S, Waring J. Understanding variation in unplanned admissions of people aged 85 and over: a systems-based approach. BMJ Open 2019; 9:e026405. [PMID: 31289067 PMCID: PMC6615796 DOI: 10.1136/bmjopen-2018-026405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
AIM To examine system characteristics associated with variations in unplanned admission rates in those aged 85+. DESIGN Mixed methods. SETTING Primary care trusts in England were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three 'improving' sites where rates had declined by more than 4% and three 'deteriorating' sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services and adult social care. PARTICIPANTS A total of 142 representatives from these organisations were interviewed to understand how policies had been developed and implemented. McKinsey's 7S framework was used as a structure for investigation and analysis. RESULTS In general, improving sites provided more evidence of comprehensive system focused strategies backed by strong leadership, enabling the development and implementation of policies and procedures to avoid unnecessary admissions of older people. In these sites, primary and intermediate care services appeared more comprehensive and better integrated with other parts of the system, and policies in emergency departments were more focused on providing alternatives to admission. CONCLUSIONS Health and social care communities which have attenuated admissions of people aged 85+ prioritised developing a shared vision and strategy, with sustained implementation of a suite of interventions.
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Affiliation(s)
- Andrew Wilson
- Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Health Sciences, University of Leicester, Leicester, UK
| | - John Bankart
- Health Sciences, University of Leicester, Leicester, UK
| | - Jay Banerjee
- Emergency Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, UK
| | - Ran Bhamra
- WolfsonSchool of Mechanical, Electrical & Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - Simon Conroy
- Health Sciences, University of Leicester, Leicester, UK
| | - Stoyan Kurtev
- Health Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Health Sciences, University of Leicester, Leicester, UK
| | | | - Justin Waring
- Centre for Health Innovation, Leadership & Learning / Nottingham University Business School, University of Nottingham, Nottingham, UK
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Cooper A, Davies F, Edwards M, Anderson P, Carson-Stevens A, Cooke MW, Donaldson L, Dale J, Evans BA, Hibbert PD, Hughes TC, Porter A, Rainer T, Siriwardena A, Snooks H, Edwards A. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 2019; 9:e024501. [PMID: 30975667 PMCID: PMC6500276 DOI: 10.1136/bmjopen-2018-024501] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/14/2018] [Accepted: 01/24/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak. DESIGN Rapid realist literature review. SETTING Emergency departments. INCLUSION CRITERIA Articles describing general practitioners working in or alongside emergency departments. AIM To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system. RESULTS Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes. CONCLUSIONS Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research. PROSPERO REGISTRATION NUMBER CRD42017069741.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | - Liam Donaldson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Peter D Hibbert
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Thomas C Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Alison Porter
- College of Medicine, Swansea University, Swansea, UK
| | - Tim Rainer
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Helen Snooks
- College of Medicine, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Agra MAC, Freitas TCSD, Caetano JÁ, Alexandre ACS, Sá GGDM, Galindo Neto NM. DISSERTAÇÕES E TESES DA ENFERMAGEM ACERCA DO SERVIÇO DE ATENDIMENTO MÓVEL DE URGÊNCIA: ESTUDO BIBLIOMÉTRICO. TEXTO & CONTEXTO ENFERMAGEM 2018. [DOI: 10.1590/0104-07072018003500016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivo: analisar a produção brasileira de dissertações e teses em enfermagem que abordem o Serviço de Atendimento Móvel de Urgência. Método: estudo bibliométrico realizado por meio do acesso virtual ao Centro de Estudos e Pesquisa em Enfermagem, da Associação Brasileira de Enfermagem, e ao Portal de Teses e Dissertações da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. A amostra foi composta por quatro teses e nove dissertações. Resultados: verificou-se maior quantitativo de estudos nas regiões Sul (38,5%) e Sudeste (46,2%), o predomínio de estudos descritivo-exploratórios, com abordagem qualitativa, a temática mais explorada foi a saúde do trabalhador no contexto pré-hospitalar móvel e a população mais investigada foram os profissionais. Conclusão: a partir dos indicadores bibliométricos, constatou-se uma limitada quantidade de trabalhos acerca do Serviço de Atendimento Móvel de Urgência nos Programas de Pós-Graduação em Enfermagem e lacunas relativas à temática nas pesquisas desses Programas. Essas constatações podem direcionar a realização de futuros estudos.
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"We don't have the infrastructure to support them at home": How health system inadequacies impact on long-term care admissions of people with dementia. Health Policy 2017; 121:1280-1287. [PMID: 29031934 DOI: 10.1016/j.healthpol.2017.09.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/18/2017] [Accepted: 09/27/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The influence of healthcare system factors on long-term care admissions has received relatively little attention. We address this by examining how inadequacies in the healthcare system impact on long-term care admissions of people with dementia. This is done in the context of the Irish healthcare system. METHODS Thirty-eight qualitative in-depth interviews with healthcare professionals and family carers were conducted. Interviews focused on participants' perceptions of the main factors which influence admission to long-term care. Interviews were analysed thematically. RESULTS The findings suggest that long-term care admissions of people with dementia may be affected by inadequacies in the healthcare system in three ways. Firstly, participants regarded the economic crisis in Ireland to have exacerbated the under-resourcing of community care services. These services were also reported to be inequitable. Consequently, the effectiveness of community care was seen to be limited. Secondly, such limits in community care appear to increase acute hospital admissions. Finally, admission of people with dementia to acute hospitals was believed to accelerate the journey towards long-term care. CONCLUSIONS Inadequacies in the healthcare system are reported to have a substantial impact on the threshold for long-term care admissions. The findings indicate that we cannot fully understand the factors that predict long-term care admission of people with dementia without accounting for healthcare system factors on the continuation of homecare.
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Pope I, Burn H, Ismail SA, Harris T, McCoy D. A qualitative study exploring the factors influencing admission to hospital from the emergency department. BMJ Open 2017; 7:e011543. [PMID: 28851767 PMCID: PMC5577896 DOI: 10.1136/bmjopen-2016-011543] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The number of emergency admissions to hospital in England and Wales has risen sharply in recent years and is a matter of concern to clinicians, policy makers and patients alike. However, the factors that influence this decision are poorly understood. We aimed to ascertain how non-clinical factors can affect hospital admission rates. METHOD We conducted semistructured interviews with 21 participants from three acute hospital trusts. Participants included 11 emergency department (ED) doctors, 3 ED nurses, 3 managers and 4 inpatient doctors. A range of seniority was represented among these roles. Interview questions were developed from key themes identified in a theoretical framework developed by the authors to explain admission decision-making. Interviews were recorded, transcribed and analysed by two independent researchers using framework analysis. FINDINGS Departmental factors such as busyness, time of day and levels of senior support were identified as non-clinical influences on a decision to admit rather than discharge patients. The 4-hour waiting time target, while overall seen as positive, was described as influencing decisions around patient admission, independent of clinical need. Factors external to the hospital such as a patient's social support and community follow-up were universally considered powerful influences on admission. Lastly, the culture within the ED was described as having a strong influence (either negatively or positively) on the decision to admit patients. CONCLUSION Multiple factors were identified which go some way to explaining marked variation in admission rates observed between different EDs. Many of these factors require further inquiry through quantitative research in order to understand their influence further.
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Affiliation(s)
- Ian Pope
- Emergency Department, Royal London Hospital, London, UK
| | - Helen Burn
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Sharif A Ismail
- Barts Health NHS Trust and Queen Mary University of London, London, UK
| | - Tim Harris
- Emergency Department, Royal London Hospital, London, UK
| | - David McCoy
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, Chan T, Chew-Graham C, Davies L, de Lusignan S, Dickens C, Drinkwater J, Dunn G, Hunter C, Joy M, Kapur N, Langer S, Lovell K, Macklin J, Mackway-Jones K, Ntais D, Salmon P, Tomenson B, Watson J. CHOICE: Choosing Health Options In Chronic Care Emergencies. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Cara Afzal
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Greater Manchester Academic Health Science Network (GM AHSN), Manchester, UK
| | - Claire Blakeley
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Amy Blakemore
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel Byford
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Elizabeth Camacho
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Tom Chan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, UK
| | - Linda Davies
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Simon de Lusignan
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Chris Dickens
- Institute of Health Research, Medical School, University of Exeter, Exeter, UK
- Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Exeter, UK
| | | | - Graham Dunn
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mark Joy
- Faculty of Science, Engineering and Computing, Kingston University, London, UK
| | - Navneet Kapur
- Manchester Academic Health Science Centre, Manchester, UK
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Susanne Langer
- Department of Psychology, Manchester Metropolitan University, Manchester, UK
| | - Karina Lovell
- Manchester Academic Health Science Centre, Manchester, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Kevin Mackway-Jones
- Manchester Academic Health Science Centre, Manchester, UK
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dionysios Ntais
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Barbara Tomenson
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jennifer Watson
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Morton S, Hames R, Kelso I, Newth A, Gnani S. Does attending general practice prior to the emergency department change patient outcomes? A descriptive, observational study of one central London general practice. LONDON JOURNAL OF PRIMARY CARE 2017; 9:28-32. [PMID: 28539975 PMCID: PMC5434562 DOI: 10.1080/17571472.2017.1280893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
BACKGROUND The challenge of keeping Emergency Department (ED) attendances down continues and timely access to general practice (GP) is often portrayed as a potential solution. SETTING One London general practice (registered population = 4900). QUESTION Does seeing a GP before attending the ED affect the outcome of a patient's ED care? METHODS Routine clinical data were extracted using SystmOne primary care computer system for all registered patients with an ED attendance between 1 October 2014 and 31 September 2015. The scanned discharge summaries from the ED and GP notes were reviewed and outcome measures extracted. RESULTS 227 patients (121 female; 104 male) attended the ED. The most common presentation was abdominal pain (n = 11). 25% of patients had seen (n = 50), or contacted by phone (n = 6), a GP about the same presenting complaint before attending the ED. Of those, 73% (n = 41/56) were referred to the ED and 49% (n = 20/41) were admitted versus 33% (n = 60/184) who self-presented (statistically significant, p = 0.05). An additional 32% of those who saw the GP first (n = 13/41) received specialist ED treatment. DISCUSSION/CONCLUSION Only 25% of patients see their GP prior to attending the ED. The majority of patients who were referred by their GP required admission or specialised ED treatment. It remains unclear why the majority of patients did not choose to contact their GP prior to attending the ED, despite urgent appointments being offered; research into patients' health beliefs in this group is required for greater understanding.
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Affiliation(s)
- S Morton
- North Kensington Medical Centre, London, UK.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - R Hames
- North Kensington Medical Centre, London, UK
| | - I Kelso
- North Kensington Medical Centre, London, UK
| | - A Newth
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - S Gnani
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Sandø A, Schultz M, Eugen-Olsen J, Rasmussen LS, Køber L, Kjøller E, Jensen BN, Ravn L, Lange T, Iversen K. Introduction of a prognostic biomarker to strengthen risk stratification of acutely admitted patients: rationale and design of the TRIAGE III cluster randomized interventional trial. Scand J Trauma Resusc Emerg Med 2016; 24:100. [PMID: 27491822 PMCID: PMC4974743 DOI: 10.1186/s13049-016-0290-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/27/2016] [Indexed: 12/22/2022] Open
Abstract
Background Several biomarkers have shown to carry prognostic value beyond current triage algorithms and may aid in initial risk stratification of patients in the emergency department (ED). It has yet to be established if information provided by biomarkers can be used to prevent serious complications or deaths. Our aim is to determine whether measurement of the blood level of the biomarker soluble urokinase plasminogen activator receptor (suPAR) can enhance early risk stratification leading to reduced mortality, lower rate of complications, and improved patient flow in acutely admitted adult patients at the ED. The main hypothesis is that the availability of suPAR can reduce all-cause mortality, assessed at least 10 months after admission, by drawing attention towards patients with an unrecognized high risk, leading to improved diagnostics and treatment. Methods The study is designed as a cross-over cluster randomized interventional trial. SuPAR is measured within 2 h after admission and immediately reported to the treating physicians in the ED. All ED physicians are educated in the prognostic capabilities of suPAR prior to the inclusion period. The inclusion period began January 11th 2016 and ends June 6th 2016. The study aims to include 10.000 patients in both the interventional and control arm. The results will be presented in 2017. Discussion The present article aims to describe the design and rationale of the TRIAGE III study that will investigate whether the availability of prognostic information can improve outcome in acutely admitted patients. This might have an impact on health care organization and decision-making. Trial registration The trial is registered at clinicaltrials.gov (ID NCT02643459, November 13, 2015) and at the Danish Data Protection agency (ID HGH-2015-042 I-Suite no. 04087).
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Affiliation(s)
- Andreas Sandø
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Martin Schultz
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark.,Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Erik Kjøller
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Birgitte Nybo Jensen
- Department of Emergency Medicine, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - Theis Lange
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730, Herlev, Denmark
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