Continuity and breaches in GP care and their associations with mortality for patients with chronic disease: an observational study using Norwegian registry data

BACKGROUND

Despite many benefits of continuity of care with a named regular GP (RGP), continuity is deteriorating in many countries.

AIM

To investigate the association between RGP continuity and mortality, in a personal list system, in addition to examining how breaches in continuity affect this association for patients with chronic diseases.

DESIGN AND SETTING

A registry-based observational study using Norwegian primary care consultation data for patients with asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, or heart failure.

METHOD

The Usual Provider of Care (UPC, value 0-1) Index was used to measure both disease-related (UPCdisease) and overall (UPCall) continuity with the RGP at the time of consultation. In most analyses, patients who changed RGP during the study period were excluded. In the combined group of all four chronic conditions, the proportion of consultations with other GPs and out-of-hours services was calculated. Cox regression models calculated the associations between continuity during 2013-2016 and mortality in 2017-2018.

RESULTS

Patients with COPD with UPCdisease <0.25 had 47% increased risk of dying within 2 years (hazard ratio 1.47, 95% confidence interval = 1.22 to 1.64) compared with those with UPCdisease ≥0.75. Mortality also increased with decreasing UPCdisease for patients with heart failure and decreasing UPCall for those with diabetes. In the combined group of chronic conditions, mortality increased with decreasing UPCall. This latter association was also found for patients who had changed RGP.

CONCLUSION

Higher disease-related and overall RGP UPC are both associated with lower mortality. However, changing RGP did not significantly affect mortality, indicating a compensatory benefit of informational and management continuity in a patient list system.

The impact of variation in out-of-hours doctors' referral practices: a Norwegian registry-based observational study

BACKGROUND

In a gatekeeping system, the individual doctor's referral practice is an important factor for hospital activity and patient safety.

OBJECTIVE

The aim of the study was to investigate the variation in out-of-hours (OOH) doctors' referral practice, and to explore these variations' impact on admissions for selected diagnoses reflecting severity, and 30-day mortality.

METHODS

National data from the doctors' claims database were linked with hospital data in the Norwegian Patient Registry. Based on the doctor's individual referral rate adjusted for local organizational factors, the doctors were sorted into quartiles of low-, medium-low-, medium-high-, and high-referral practice. The relative risk (RR) for all referrals and for selected discharge diagnoses was calculated using generalized linear models.

RESULTS

The OOH doctors' mean referral rate was 110 referrals per 1,000 consultations. Patients seeing a doctor in the highest referring practice quartile had higher likelihood of being referred to hospital and diagnosed with the symptom of pain in throat and chest, abdominal pain, and dizziness compared with the medium-low quartile (RR 1.63, 1.49, and 1.95). For the critical conditions of acute myocardial infarction, acute appendicitis, pulmonary embolism, and stroke, we found a similar, but weaker, association (RR 1.38, 1.32, 1.24, and 1.19). The 30-day mortality among patients not referred did not differ between the quartiles.

CONCLUSIONS

Doctors with high-referral practice referred more patients who were later discharged with all types of diagnoses, including serious and critical conditions. With low-referral practice, severe conditions might have been overlooked, although the 30-day mortality was not affected.

Continuity of care and mortality for patients with chronic disease: an observational study using Norwegian registry data

BACKGROUND

Research on continuity of care (CoC) is mainly conducted in primary care and has received little acknowledgment in other levels of care. This study sought to investigate CoC across care levels for patients with selected chronic diseases, along with its association with mortality.

METHODS

In a registry-based cohort study, patients with ≥1 consultation in primary or specialist healthcare or hospital admission with asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, or heart failure in 2012 were linked to disease-related consultation data in 2013-2016. CoC was measured by Usual Provider of Care index (UPC) and Bice-Boxermann continuity of care score (COCI). Values equal to one were categorized into one group and the rest into three equal groups (tertiles). The association with mortality was determined by Cox regression models.

RESULTS

The highest mean UPCtotal was measured for patients with diabetes mellitus (0.58) and the lowest for those with asthma (0.46). The population with heart failure had the highest death rate (26.5). In adjusted Cox regression analyses for COPD, mortality was 2.6 times higher (95% CI 2.25-3.04) for patients in the lowest tertile of continuity compared to those with UPCtotal = 1. Patients with diabetes mellitus and heart failure showed similar results.

CONCLUSION

CoC was moderate to high for disease-related contacts across care levels. A higher mortality associated with lower CoC was observed for patients with COPD, diabetes mellitus, and heart failure. A similar, but not statistically significant trend was found for patients with asthma. This study suggests that higher CoC across levels of care can decrease mortality.

Prevalence and predictors of post-COVID-19 symptoms in general practice - a registry-based nationwide study

BACKGROUND

With Norwegian national registry data, we assessed the prevalence of post-COVID-19 symptoms at least 3 months after confirmed infection, and whether sociodemographic factors and pre-pandemic health problems were risk factors for these symptoms.

METHODS

All persons with a positive SARS-CoV-2 PCR test from February 2020 to February 2021 (exposed) were compared to a group without a positive test (unexposed) matched on age, sex, and country of origin. We used Cox regression to estimate hazard ratios (HR) for 18 outcome symptoms commonly described as post-COVID-19 related, registered by GPs. We compared relative risks (RR) for fatigue, memory disturbance, or shortness of breath among exposed and unexposed using Poisson regression models, assessing sex, age, education, country of origin, and pre-pandemic presence of the same symptom and comorbidity as possible risk factors, with additional analyses to assess hospitalisation for COVID-19 as a risk factor among exposed.

RESULTS

The exposed group (N = 53 846) had a higher prevalence of most outcome symptoms compared to the unexposed (N = 485 757), with the highest risk for shortness of breath (HR 2.75; 95%CI 2.59-2.93), fatigue (2.08; 2.00-2.16) and memory disturbance (1.41;1.26-1.59). High HRs were also found for disturbance of smell/taste and hair loss, but frequencies were low. Concerning risk factors, sociodemographic factors were at large similarly associated with outcome symptoms in both groups. Registration of the outcome symptom before the pandemic increased the risk for fatigue, memory disturbance and shortness of breath after COVID-19, but these associations were weaker among exposed. Comorbidity was not associated with fatigue and shortness of breath in the COVID-19 group. For memory disturbance, the RR was slightly increased with the higher comorbidity score both among exposed and unexposed.

CONCLUSION

COVID-19 was associated with a range of symptoms lasting more than three months after the infection.

Effect of sense of coherence on long-term work participation among rehabilitation patients: a longitudinal study

OBJECTIVE

To investigate the causal effect of sense of coherence on long-term work participation after rehabilitation, including stratification by age and diagnoses.

DESIGN

Longitudinal cohort study.

PARTICIPANTS

Patients aged ≤ 60 years, employed and accepted for somatic interprofessional rehabilitation in 2015 (n = 192).

METHODS

Patients reported sense of coherence before rehabilitation in 2015 and mental and physical functioning in 2016. Register data were used to measure work participation during 2018 and days working without social security benefits during 2016-18. Regression models were used to explore the total effect of sense of coherence and the possible mediation of functioning. Results are reported as odds ratios (95% confidence intervals).

RESULTS

During 2018, 77% of the total study cohort participated in work activities. The subgroup with musculoskeletal diagnoses had the fewest days of working without social security benefits. A causal relationship was found between sense of coherence and long-term work participation. Some of the effect of sense of coherence was mediated by mental functioning. The total effect of sense of coherence was strongest for patients with musculo-skeletal diagnoses (work participation: 1.11 (1.05, 1.17), days working without social security benefits: 1.05 (0.01, 109)).

CONCLUSION

Improving coping resources may be beneficial to facilitate long-term work participation after injury or illness, especially for individuals with musculoskeletal diagnoses.

Nutritional risk, nutrition plan and risk of death in older health care service users with chronic diseases: A register-based cohort study

BACKGROUND AND AIMS

Nutritional risk in older health care service users is a well-known challenge. Nutritional risk screening and individualised nutrition plans are common strategies for preventing and treating malnutrition. The aim of the current study was to investigate whether nutritional risk is associated with an increased risk of death and whether a nutrition plan to those at nutritional risk could reduce this potential risk of death in community health care service users over 65 years of age.

METHODS

We conducted a register-based, prospective cohort study on older health care service users with chronic diseases. The study included persons ≥65 years of age receiving health care services from all municipalities in Norway from 2017 to 2018 (n = 45,656). Data on diagnoses, nutritional risk, nutrition plan and death were obtained from the Norwegian Registry for Primary Health Care (NRPHC) and the Norwegian Patient Registry (NPR). We used Cox regression models to estimate the associations of nutritional risk and use of a nutrition plan with the risk of death within three and six months. Analyses were performed within the following diagnostic strata: chronic obstructive pulmonary disease (COPD), dementia, type 2 diabetes, stroke, osteoporosis and heart failure. The analyses were adjusted for age, gender, living situation and comorbidity.

RESULTS

Of the 45,656 health care service users, 27,160 (60%) were at nutritional risk, and 4437 (10%) and 7262 (16%) died within three and six months, respectively. Among those at nutritional risk, 82% received a nutrition plan. Health care service users at nutritional risk had an increased risk of death compared to health care service users not at nutritional risk (13% vs 5% and 20% vs 10% at three and six months). Adjusted hazard ratios (HRs) for death within six months were 2.26 (95% confidence interval (CI): 1.95, 2.61) for health care service users with COPD, 2.15 (1.93, 2.41) for those with heart failure, 2.37 (1.99, 2.84) for those with osteoporosis, 2.07 (1.80, 2.38) for those with stroke, 2.65 (2.30, 3.06) for those with type 2 diabetes and 1.94 (1.74, 2.16) for those with dementia. The adjusted HRs were larger for death within three months than death within six months for all diagnoses. Nutrition plans were not associated with the risk of death for health care service users at nutritional risk with COPD, dementia or stroke. For health care service users at nutritional risk with type 2 diabetes, osteoporosis or heart failure, nutrition plans were associated with an increased risk of death within both three and six months (adjusted HR 1.56 (95% CI: 1.10, 2.21) and 1.45 (1.11, 1.88) for type 2 diabetes; 2.20 (1.38, 3.51) and 1.71 (1.25, 2.36) for osteoporosis and 1.37 (1.05, 1.78) and 1.39 (1.13, 1.72) for heart failure).

CONCLUSIONS

Nutritional risk was associated with the risk of earlier death in older health care service users with common chronic diseases in the community. Nutrition plans were associated with a higher risk of death in some groups in our study. This may be because we could not control sufficiently for disease severity, the indication for providing a nutrition plan or the degree of implementation of nutrition plans in community health care.

Young adults with depression: A registry-based longitudinal study of work-life marginalisation. The Norwegian GP-DEP study

AIMS

To explore the association between a depression diagnosis in young adulthood and risk of marginalisation at age 29 years, among those who had completed upper secondary school and those who had not completed at age 21.

METHODS

In a longitudinal cohort study based on nationwide registers we followed 111,558 people from age 22-29 years. Outcomes were risk of marginalisation and educational achievement at age 29. Exposure was a diagnosed depression at ages 22-26 years. Comorbid mental and somatic health conditions, gender and country of origin were covariates. Relative risks were estimated with Poisson regression models, stratified by educational level at age 21.

RESULTS

For people who had not completed upper secondary school at age 21 years, a depression diagnosis at age 22-26 increased the risk of low income (relative risk = 1.33; 95% confidence interval = 1.25-1.40), prolonged unemployment benefit (1.46; 1.38-1.55) and social security benefit (1.56; 1.41-1.74) at age 29 compared with those with no depression. Among those who had completed upper secondary school at age 21 years, depression increased the risk of low income (1.71; 1.60-1.83), prolonged unemployment benefit (2.17; 2.03-2.31), social security benefit (3.62; 2.91-4.51) and disability pension (4.43; 3.26-6.01) compared with those with no depression. Mental comorbidity had a significant impact on risk of marginalisation in both groups.

CONCLUSIONS

Depression in one's mid-20s significantly increases the risk of marginalisation at age 29 years, and comorbid mental health conditions reinforce this association. Functional ability should be given priority in depression care in early adulthood to counteract marginalisation.

Lower levels of physical activity volume are beneficial, and it's never too late to start: Results from the HUNT Study, Norway

AIMS

We aimed to explore (a) how different patterns of physical activity (PA) over time (36 years) were associated with all-cause and cause-specific mortality, (b) if the association was similar for males and females and for different body mass levels and (c) how change in PA was associated with mortality for subjects who started out as physically inactive.

METHODS

The study is based on the prospective population-based cohort Trøndelag Health Study (HUNT) from 1984 to 2020, across four study waves. Data were linked to the Norwegian Cause of Death Registry. There were 123,005 participants, divided into three groups: persistently active, persistently inactive and mixed, with two cut-offs for PA: 60 and 150 minutes per week. The results are reported as cumulative incidence and hazard ratios (HRs).

RESULTS

At 60 minutes of PA per week, 8% of participants were persistently inactive, 15% were persistently active and 77% had a mixed pattern. At 150 minutes, the corresponding numbers were 32%, 2% and 65%. Compared to the persistently inactive group, for the 60-minute cut-off, the mixed group had an all-cause mortality HR of 0.83 (95% confidence interval (CI) 0.70-0.98), and the persistently active group had an HR of 0.51 (95% CI 0.40-0.65). For the 150-minute cut-off, the corresponding HRs were 0.84 (95% CI 0.75-0.94) and 0.48 (95% CI 0.26-0.88). The patterns were similar for males and females and across body mass index levels. Initially inactive participants had lower mortality if they ended up physically active, regardless of their activity level at an intermediate time point.

CONCLUSIONS

At least 60 minutes of PA per week was associated with a marked reduction in mortality when this was a lasting habit over three decades. Given that six times as many people reach this less ambitious goal, it is vital to encourage all levels of PA in public health promotion. Any increase in PA during the lifespan is beneficial.

Comparison of depression care provided in general practice in Norway and the Netherlands: registry-based cohort study (The Norwegian GP-DEP study)

BACKGROUND

Depression is highly prevalent in general practice, and organisation of primary health care probably affects the provision of depression care. General practitioners (GPs) in Norway and the Netherlands fulfil comparable roles. However, primary care teams with a mental health nurse (MHN) supplementing the GP have been established in the Netherlands, but not yet in Norway. In order to explore how the organisation of primary mental care affects care delivery, we aimed to examine the provision of GP depression care across the two countries.

METHODS

Registry-based cohort study comprising new depression episodes in patients aged ≥ 18 years, 2011-2015. The Norwegian sample was drawn from the entire population (national health registries); 297,409 episodes. A representative Dutch sample (Nivel Primary Care Database) was included; 27,362 episodes. Outcomes were follow-up consultation(s) with GP, with GP and/or MHN, and antidepressant prescriptions during 12 months from the start of the depression episode. Differences between countries were estimated using negative binomial and Cox regression models, adjusted for patient gender, age and comorbidity.

RESULTS

Patients in the Netherlands compared to Norway were less likely to receive GP follow-up consultations, IRR (incidence rate ratio) = 0.73 (95% confidence interval (CI) 0.71-0.74). Differences were greatest among patients aged 18-39 years (adj IRR = 0.64, 0.63-0.66) and 40-59 years (adj IRR = 0.71, 0.69-0.73). When comparing follow-up consultations in GP practices, including MHN consultations in the Netherlands, no cross-national differences were found (IRR = 1.00, 0.98-1.01). But in age-stratified analyses, Dutch patients 60 years and older were more likely to be followed up than their Norwegian counterparts (adj IRR = 1.21, 1.16-1.26). Patients in the Netherlands compared to Norway were more likely to receive antidepressant drugs, adj HR (hazard ratio) = 1.32 (1.30-1.34).

CONCLUSIONS

The observed differences indicate that the organisation of primary mental health care affects the provision of follow-up consultations in Norway and the Netherlands. Clinical studies are needed to explore the impact of team-based care and GP-based care on the quality of depression care and patient outcomes.

Factors associated with self-rated health in primary care in the South-Western health zone of Malawi

Background

Self-rated health (SRH) is a single-item measure of current health, which is often used in community surveys and has been associated with various objective health outcomes. The prevalence and factors associated with SRH in Sub-Saharan Africa remain largely unknown. This study sought to investigate: (1) the prevalence of poor SRH, (2) possible associations between SRH, and socio-demographic and clinical parameters, and (3) associations between SRH and the patients’ assessment of the quality of primary care.

Methods

A cross-sectional study was conducted in 12 primary care facilities in Blantyre, Neno, and Thyolo districts of Malawi among 962 participants who sought care in these facilities. An interviewer-administered questionnaire containing the Malawian primary care assessment tool, and questions on socio-demographic characteristics and self-rated health was used for data collection. Descriptive statistics were used to determine the distribution of variables of interest and binary logistic regression was used to determine factors associated with poor SRH.

Results

Poor SRH was associated with female sex, increasing age, decreasing education, frequent health care attendance, and with reported disability. Patients content with the service provided and who reported higher scores of relational continuity from their health care providers reported better SRH as compared with others.

Conclusion

This study reports findings from a context where SRH is scarcely examined. The prevalence of poor SRH in Malawi is in line with findings from clinical populations in other countries. The associations between poor SRH and socio-demographic factors are also known from other populations. SRH might be improved by emphasizing continuity of care in primary care services.

Function, coping and health as predictors of sick leave after rehabilitation

Background

Function, coping and health are central factors in rehabilitation after injury or sickness. To investigate how these factors are associated with sick leave during 12 months after rehabilitation is the aim of this study.

Methods

A sample of 412 rehabilitation patients ≤ 67years were included. They were all employed, and referred to inter-professional rehabilitation in western Norway. Rehabilitation consisted of physical activity/exercise, cognitive approaches and pain management. In two surveys patients reported mental (MCS) and physical (PCS) function (SF-36), self-perceived health (EQ-VAS) and coping (SOC-13). Register data on sick leave during 12 months in the calendar year after rehabilitation was retrieved from Statistics Norway and categorised to; non, (n = 168), ≤ 364 days (n = 152) and 365 days (n = 92). Ordinal regression was used to analyse association between sick leave and MCS, PCS, EQ-VAS and SOC-13, adjusted for age, sex and diagnoses.

Results

The levels of MCS and PCS (SF-36) were found to be associated with sick leave; OR 0.96, 95% CI 0.92-0.99, p = 0.004 and OR 0.93, 95% CI 0.90-0.97, p &lt; 0.001, respectively (Pseudo R2 = 0.1133). EQ-VAS and SOC-13 were significant predictors of sick leave in crude analysis (EQ-VAS: OR 0.97, 95% CI 0.96-0.98, p &lt; 0.001. SOC-13: OR 0.98, 95% CI 0.95-0.98, p &lt; 0.001), but not in the fully adjusted model (EQ-VAS: OR 0.98, 95% CI 0.96-1.01, p = 0.178. SOC-13: OR 0.99, 95% CI 0.99-1.03, p = 0.479).

Conclusions

Patientś self-reported mental and physical function were associated with sick leave 12 months after inter-professional rehabilitation. Higher level of function was associated with no sick leave. In our study, patient’s self-reported health and coping were not associated with sick leave. This suggest that interventions for functional improvement are beneficial in health care strategies to help patients return to work after injury or sickness.

Key messages

• Achieved higher physical and mental function after rehabilitation seems to contribute to reduced sick leave after injury or sickness.

• Improving function should remain a central factor in rehabilitation.

Practice characteristics influencing variation in provision of depression care in general practice in Norway; a registry-based cohort study (The Norwegian GP-DEP study)

BACKGROUND

There is growing evidence of variation in treatment for patients with depression, not only across patient characteristics, but also with respect to the organizational and structural framework of general practitioners' (GPs') practice. However, the reasons for these variations are sparsely examined. This study aimed to investigate associations of practice characteristics with provision of depression care in general practices in Norway.

METHODS

A nationwide cohort study of residents aged ≥ 18 years with a new depression episode in general practice during 2009-2015, based on linked registry data. Exposures were characteristics of GP practice: geographical location, practice list size, and duration of GP-patient relationship. Outcomes were talking therapy, antidepressant medication and sick listing provided by GP during 12 months from date of diagnosis. Associations between exposure and outcome were estimated using generalized linear models, adjusted for patients' age, gender, education and immigrant status, and characteristics of GP practice.

RESULTS

The study population comprised 285 113 patients, mean age 43.5 years, 61.6% women. They were registered with 5 574 GPs. Of the patients, 52.5% received talking therapy, 34.1% antidepressant drugs and 54.1% were sick listed, while 17.3% received none of the above treatments. Patients in rural practices were less likely to receive talking therapy (adjusted relative risk (adj RR) = 0.68; 95% confidence interval (CI) = 0.64-0.73) and more likely to receive antidepressants (adj RR = 1.09; 95% CI = 1.04-1.14) compared to those in urban practices. Patients on short practice lists were more likely to receive medication (adj RR = 1.08; 95% CI = 1.05-1.12) than those on long practice lists. Patients with short GP-patient relationship were more likely to receive talking therapy (adj RR = 1.20; 95% CI = 1.17-1.23) and medication (adj RR = 1.08; 95% CI = 1.04-1.12), and less likely to be sick-listed (RR = 0.88; 95% CI = 0.87-0.89), than patients with long GP-patient relationship.

CONCLUSIONS

Provision of GP depression care varied with practice characteristics. Talking therapy was less commonly provided in rural practices and among those with long-lasting GP-patient relationship. These differences may indicate some variation, and therefore, its reasons and clinical consequences need further investigation.

Continuity of care for patients with chronic disease: a registry-based observational study from Norway

BACKGROUND

Continuity of care (CoC) is accepted as a core value of primary care and is especially appreciated by patients with chronic conditions. Nevertheless, there are few studies investigating CoC for these patients across levels of healthcare.

OBJECTIVE

This study aims to investigate CoC for patients with somatic chronic diseases, both with regular general practitioners (RGPs) and across care levels.

METHODS

We conducted a registry-based observational study by using nationwide consultation data from Norwegian general practices, out-of-hours services, hospital outpatient care, and private specialists with public contracts. Patients with diabetes mellitus (type I or II), asthma, chronic obstructive pulmonary disease, or heart failure in 2012, who had ≥2 consultations with these diagnoses during 2014 were included. CoC was measured during 2014 by using the usual provider of care (UPC) index and Bice-Boxerman continuity of care score (COCI). Both indices have a value between 0 and 1.

RESULTS

Patients with diabetes mellitus comprised the largest study population (N = 79,165) and heart failure the smallest (N = 4,122). The highest mean UPC and COCI were measured for patients with heart failure, 0.75 and 0.77, respectively. UPC increased gradually with age for all diagnoses, while COCI showed this trend only for asthma. Both indices had higher values in urban areas.

CONCLUSIONS

Our findings suggest that CoC in Norwegian healthcare system is achieved for a majority of patients with chronic diseases. Patients with heart failure had the highest continuity with their RGP. Higher CoC was associated with older age and living in urban areas.

Nutritional Risk Is Associated with Earlier Death in Older Service Users with Common Chronic Diseases

Objectives

The objective of the study was to investigate associations of nutritional risk with mortality in older service users with common chronic diseases.

Methods

We used data from 2017–2018 in national registries in Norway (KPR and NPR) to investigate associations of nutritional risk with six months mortality in a cohort of service users ≥65 years (n = 45,701, mean age 83 years(range 63–106)) with common chronic diseases (COPD, heart failure, osteoporosis, stroke, type 2 diabetes or dementia). Nutritional risk status of the service users was assessed using validated screening tools recommended in the Norwegian guideline on prevention and treatment of malnutrition (either MNA or MUST). We applied Cox regression models to analyse associations of nutritional risk with death in service users with the six chronic diseases. The analyses were done on diagnose specific strata, and adjusted for age, gender and living situation (i.e., living with others vs living alone).

Results

Of the 45,701 service users, 27,160 (59%) were at nutritional risk and 7,269 (16%) died within six months. Service users that were at nutritional risk had increased risk of death compared to service users not at nutritional risk (20% vs 10%). Adjusted Hazard Ratios (HR) were 2.26 (95% confidence interval: 1.95, 2.61) for service users with COPD, 2.15(1.93, 2.41) for heart failure, 2.37(1.99, 2.84) for osteoporosis, 2.07(1.80, 2.38) for stroke, 2.65(2.30, 3.06) for type 2 diabetes and 1.94(1.74, 2.16) for service users with dementia.

Conclusions

Nutritional risk in older service users with common chronic diseases was strongly associated with earlier death. The finding warrant increased attention to prevention and treatment of malnutrition in community health services.

Funding Sources

The project was funded by Helse Fonna Local Health Authority, Norway.

The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage

Background

Patients referred to specialised mental health care are usually triaged based on referral information provided by general practitioners. However, knowledge about this system’s ability to ensure timely access to and equity in specialised mental health care is limited. We aimed to investigate to the degree to which patient triage, based on referral letter information, corresponds to triage based on a hospital specialist’s consultation with the patient, and whether the degree of correspondence is affected by the quality of the referral letter.

Methods

We gathered information from three specialised mental health centres in Norway regarding patients that were referred and offered health care (N = 264). Data consisted of triage decisions for each patient (i.e., the hospital specialist’s assessment of maximum acceptable waiting time), which were determined on the basis of a) referral information and b) meeting the patient. Referral letter quality was evaluated using the Quality of Referral information-Mental Health checklist. The reliability of priority setting and the impact of referral letter quality on this measure were investigated using descriptive analyses, binary logistic regression and Nadaraya-Watson kernel regression.

Results

In 143 (54%) cases, the triage decision based on referral information corresponded with the decision based on patient consultation. In 70 (27%) cases, the urgency of need for treatment was underestimated when based on referral information compared with that based on information from patient consultation. Referral letter quality could not explain the differences between the two triage decisions. However, when a cut-off value of 7 on the Quality of Referral information-Mental Health scale was used, low-quality letters were found more frequently among patients whose urgency of need was underestimated, compared with those whose need was overestimated.

Conclusions

Deciding the urgency of patient need for specialised mental health care based on referral information is a reliable system in many situations. However, the possibility of under- and overestimation is present, implying risks to patient safety and inappropriate use of resources. Improving the content of referral letters does not appear to reduce this risk when the letters are of acceptable quality.

Trial registration

NCT01374035.

Construction and validation of a morbidity index based on the International Classification of Primary Care

OBJECTIVES

In epidemiological studies it is often necessary to describe morbidity. The aim of the present study is to construct and validate a morbidity index based on the International Classification of Primary Care (ICPC-2).

DESIGN AND SETTING

This is a cohort study based on linked data from national registries. An ICPC morbidity index was constructed based on a list of longstanding health problems in earlier published Scottish data from general practice and adapted to diagnostic ICPC-2 codes recorded in Norwegian general practice 2015 - 2017.

SUBJECTS

The index was constructed among Norwegian born people only (N = 4 509 382) and validated in a different population, foreign-born people living in Norway (N = 959 496).

MAIN OUTCOME MEASURES

Predictive ability for death in 2018 in these populations was compared with the Charlson index. Multiple logistic regression was used to identify morbidities with the highest odds ratios (OR) for death and predictive ability for different combinations of morbidities was estimated by the area under receiver operating characteristic curves (AUC).

RESULTS

An index based on 18 morbidities was found to be optimal, predicting mortality with an AUC of 0.78, slightly better than the Charlson index (AUC 0.77). External validation in a foreign-born population yielded an AUC of 0.76 for the ICPC morbidity index and 0.77 for the Charlson index.

CONCLUSIONS

The ICPC morbidity index performs equal to the Charlson index and can be recommended for use in data materials collected in primary health care.Key pointsThis is the first morbidity index based on the International Classification of Primary Care, 2^nd edition (ICPC-2)It predicted mortality equal to the Charlson index and validated acceptably in a different populationThe ICPC morbidity index can be used as an adjustment variable in epidemiological research in primary care databases.

Patient experiences with depression care in general practice: a qualitative questionnaire study

OBJECTIVE

To investigate patient experiences and preferences regarding depression care in general practice.

DESIGN AND SETTING

A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis.

SUBJECTS

250 persons completed the web-based survey, 86% were women.

RESULTS

The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful.

CONCLUSIONS

Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment.KEY POINTSDepression is common, and GPs are often patients' first point of contact when they seek help.  • Patients who feel depressed appreciate help from their GP.  • Patients prefer an empathetic GP who listens attentively and acknowledges their problems.  • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.

Factors associated with self-rated health in primary care in the South-Western health zone of Malawi

BACKGROUND

Self-rated health (SRH) is a single-item measure of current health, which is often used in community surveys and has been associated with various objective health outcomes. The prevalence and factors associated with SRH in Sub-Saharan Africa remain largely unknown. This study sought to investigate: (1) the prevalence of poor SRH, (2) possible associations between SRH, and socio-demographic and clinical parameters, and (3) associations between SRH and the patients' assessment of the quality of primary care.

METHODS

A cross-sectional study was conducted in 12 primary care facilities in Blantyre, Neno, and Thyolo districts of Malawi among 962 participants who sought care in these facilities. An interviewer-administered questionnaire containing the Malawian primary care assessment tool, and questions on socio-demographic characteristics and self-rated health was used for data collection. Descriptive statistics were used to determine the distribution of variables of interest and binary logistic regression was used to determine factors associated with poor SRH.

RESULTS

Poor SRH was associated with female sex, increasing age, decreasing education, frequent health care attendance, and with reported disability. Patients content with the service provided and who reported higher scores of relational continuity from their health care providers reported better SRH as compared with others.

CONCLUSION

This study reports findings from a context where SRH is scarcely examined. The prevalence of poor SRH in Malawi is in line with findings from clinical populations in other countries. The associations between poor SRH and socio-demographic factors are also known from other populations. SRH might be improved by emphasizing continuity of care in primary care services.

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

BACKGROUND

Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere.

AIM

To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality.

DESIGN AND SETTING

Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs.

METHOD

Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses.

RESULTS

Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years.

CONCLUSION

Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.

Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study

Background

General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral.

Methods

A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR.

Results

Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men.

Conclusions

The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.

Continuity of care, measurement and association with hospital admission and mortality: a registry-based longitudinal cohort study

OBJECTIVE

To assess whether continuity of care (COC) with a general practitioner (GP) is associated with mortality and hospital admissions for older patients We argue that the conventional continuity measure may overestimate these associations. To better reflect COC as a GP quality indicator, we present an alternative, service-based measure.

DESIGN

Registry-based, population-level longitudinal cohort study.

SETTING

Linked data from Norwegian administrative healthcare registries, including 3989 GPs.

PARTICIPANTS

757 873 patients aged 60-90 years with ≥2 contacts with a GP during 2016 and 2017.

MAIN OUTCOME MEASURE

All-cause emergency hospital admissions, emergency admissions for ambulatory care sensitive conditions, and mortality, in 2018.

RESULTS

We assessed COC using the conventional usual provider of care index (UPC^patient) and an alternative/supplementary index (UPC^{GP list}) based on the COC for all other patients enlisted with the same preferred GP.For both indices, the mean index score was 0.78. Our model controls for demographic and socioeconomic characteristics, prior healthcare use and municipality-fixed effects. Overall, UPC^{GP list} shows a much weaker association between COC and the outcomes. For both indices, there is a negative relationship between COC and hospital admissions. A 0.2-point increase in the index score would reduce admissions for ambulatory care sensitive conditions by 8.1% (CI 7.1% to 9.1%) versus merely 1.9% (0.2% to 3.5%) according to UPC^patient and UPC^{GP list}, respectively. Using UPC^{GP list}, we find that mortality is no longer associated with COC. There was greater evidence for an association between COC and all-cause admissions among patients with low education.

CONCLUSIONS

A continuity measure based on each patient's contacts with own preferred GP may overestimate the importance of COC as a feature of the GP practice. An alternative, service-based measure of continuity could be suitable as a quality measure in primary healthcare. Facilitating continuity should be considered a health policy measure to reduce inequalities in health.

Trends in treatment for patients with depression in general practice in Norway, 2009-2015: nationwide registry-based cohort study (The Norwegian GP-DEP Study)

Background

Depression is highly prevalent, but knowledge is scarce as to whether increased public awareness and strengthened government focus on mental health have changed how general practitioners (GPs) help their depressed patients. This study aimed to examine national time trends in GP depression care and whether trends varied regarding patient gender, age, and comorbidity.

Methods

Nationwide registry-based cohort study, Norway. The study population comprised all residents aged 20 years or older with new depression diagnoses recorded in general practice, 2009–2015. We linked reimbursement claims data from all consultations in general practice for depression with information on demographics and antidepressant medication. The outcome was type(s) of GP depression care during 12 months from the date of diagnosis: (long) consultation, talking therapy, antidepressant drug treatment, sickness absence certification, and referral to secondary mental health care. Covariates were patient gender, age, and comorbidity. The data are presented as frequencies and tested with generalized linear models.

Results

We included 365,947 new depression diagnoses. Mean patient age was 44 years (SD = 16), 61.9 % were women, 41.2 % had comorbidity. From 2009 to 2015, proportions of patients receiving talking therapy (42.3–63.4 %), long consultations (56.4–71.8 %), and referral to secondary care (16.6–21.6 %) increased, while those receiving drug treatment (31.3–25.9 %) and sick-listing (58.1–50 %) decreased. The trends were different for gender (women had a greater increase in talking therapy and a smaller decrease in sick-listing, compared to men), age (working-aged patients had a smaller increase in talking therapy, a greater increase in long consultations, and a smaller decrease in antidepressant drug use, compared to older patients) and comorbidity (patients with mental comorbidity had a smaller increase in talking therapy and a greater increase in long consultations, compared to those with no comorbidity and somatic comorbidity).

Conclusions

The observed time trends in GP depression care towards increased provision of psychological treatment and less drug treatment and sick-listing were in the desired direction according to Norwegian health care policy. However, the large and persistent differences in treatment rates between working-aged and older patients needs further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06712-w.

Variation in general practitioners' depression care following certification of sickness absence: a registry-based cohort study

BACKGROUND

Depression is more prevalent among women and people with low socio-economic status. Uncertainties exist about how general practitioner (GP) depression care varies with patients' social position.

OBJECTIVE

To investigate associations between patients' gender and educational status combined and GP depression care following certification of sickness absence.

METHODS

Nationwide registry-based cohort study, Norway, 2012-14. Reimbursement claims data from all consultations in general practice for depression were linked with information on socio-demographic data, social security benefits and depression medication. The study population comprised all individuals aged 25-66 years with taxable income, sick-listed with a new depression diagnosis in general practice in 2013 (n = 8857). We defined six intersectional groups by combining educational level and gender. The outcome was type of GP depression care during sick leave: follow-up consultation(s), talking therapy, medication and referral to secondary care. Associations between intersectional groups and outcome were estimated using generalized linear models.

RESULTS

Among long-term absentees (17 days or more), highly educated women were less likely to receive medication compared to all other patient groups [relative risk (RR) ranging from 1.17 (95% confidence interval 1.03-1.33) to 1.49 (1.29-1.72)] and more likely to receive talking therapy than women with medium [RR = 0.90 (0.84-0.98)] or low [RR = 0.91 (0.85-0.98)] education.

CONCLUSIONS

Our findings suggest that GPs provide equitable depression care regarding consultations and referrals for all intersectional groups but differential drug treatment and talking therapy for highly educated women. GPs need to be aware of these variations to provide personalized care and to prevent reproducing inequity.

Self-rated health in adolescence as a predictor of 'multi-illness' in early adulthood: A prospective registry-based Norwegian HUNT study

Self-rated health (SRH) is a marker of future health and a possible predictor of future multimorbidity, which is a major challenge for population health and health care. There is a lack of studies on adolescent SRH and patterns of health problems across the transitional period from adolescence to early adulthood. Therefore, this study aimed to identify groups of people with similar health problems in early adulthood and explore the predictive value of adolescent SRH on the group classification after a period of 10–19 years. Data from 8828 adolescents participating in the Young HUNT-1 survey (1995–1997) were linked to the Norwegian registry of general practitioner (GP) claims, which includes diagnoses recorded in GP consultations in 2006–2014. We used latent class analysis (LCA) to identify groups of patients with similar health problems in early adulthood and explored SRH as a predictor of class membership using latent class regression, adjusting for baseline chronic disease, frequency of health care attendance, sex and age. The mean age at baseline was 16 years, and 50% of the participants were female. SRH was reported as very good by 28%, good by 61% and not good by 11%. We identified five groups of patient classification (classes): Healthy (35%), Infections and general problems (26%), Musculoskeletal problems (21%), Psychological problems (6%) and Multi-illness (13%). We found a gradual increase in the probability of belonging to the Healthy class with better SRH, and an inverse pattern for the Psychological and Multi-illness classes. This pattern remained after adjusting for baseline variables. In conclusion, there is a clear association between adolescent SRH and the risk of having multi-illness in early adulthood, seen as a proxy for later multimorbidity. This finding warrants greater attention to SRH in adolescence as a possible indicator in targeted prevention of future health problems.

•

Adolescent self-rated health (SRH) predicted health problems 10–19 years later.

•

Patients were classified into five groups with similar patterns of health problems.

•

Better SRH increased the probability of adults belonging to the healthiest group.

•

Not good SRH tripled the risk for multi-illness compared to very good SRH.

•

Low SRH in adolescence is a possible predictor of multimorbidity in adulthood.

Patient-reported depression treatment and future treatment preferences: an observational study in general practice

BACKGROUND

Depression is prevalent in general practice, but few studies have explored patient-reported depression care.

AIM

To investigate patient-reported treatment received for depression and future treatment preferences among adult patients visiting their GP, and to evaluate the associations with sex, age and educational level.

DESIGN AND SETTING

A cross-sectional survey was conducted in general practices in Norway from 2016 to 2017.

METHODS

Altogether, 2335 consecutive patients (response rate, 89.2%) in the GPs' waiting rooms answered a questionnaire about their received depression treatment and treatment preferences in case of future depression.

RESULTS

The study population (N = 2239) had a mean age of 48.6 ± 17.7 years (range 18-91), 60.1% were women. Of the 770 patients reporting to have received depression treatment, 39.1% were treated exclusively by their GP while 52.5% also were referred to a psychologist/psychiatrist. Older age was positively associated with medication and negatively associated with referrals to psychologist/psychiatrist. People with high education had lower odds for receiving medication (odds ratios [OR], 0.49; 95% confidence intervals [CI]: 0.30-0.80) compared to those with low education. If future depression, 81.6% of the respondents would discuss this with their GP, 60.9% would prefer talking therapy with their GP, 22.5% medication, and 52.9% referral to psychologist or psychiatrist.

CONCLUSION

One-third of the patients attending their GPs had consulted with them at some time concerning depression the case of future depression, most patients preferred talking therapy with the GP. This finding warrants increased research focus on the GP's role in depression care.

General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study

Background

Primary care doctors have a gatekeeper function in many healthcare systems, and strategies to reduce emergency hospital admissions often focus on general practitioners’ (GPs’) and out-of-hours (OOH) doctors’ role. The aim of the present study was to investigate these doctors’ role in emergency admissions to somatic hospitals in the Norwegian public healthcare system, where GPs and OOH doctors have a distinct gatekeeper function.

Methods

A cross-sectional analysis was performed by linking data from the Norwegian Patient Registry (NPR) and the physicians’ claims database. The referring doctor was defined as the physician who had sent a claim for a consultation with the patient within 24 h prior to an emergency admission. If there was no claim registered prior to hospital arrival, the admission was defined as direct, representing admissions from ambulance services, referrals from nursing home doctors, and admissions initiated by in-hospital doctors.

Results

In 2014 there were 497,587 emergency admissions to somatic hospitals in Norway after excluding birth related conditions. Direct admissions were most frequent (43%), 31% were referred by OOH doctors, 25% were referred by GPs, whereas only 2% were referred from outpatient clinics or private specialists with public contract. Direct admissions were more common in central areas (52%), here GPs’ referrals constituted only 16%. The prehospital paths varied with the hospital discharge diagnosis. For anaemias, 46–49% were referred by GPs, for acute appendicitis and mental/alcohol related disorders 52 and 49% were referred by OOH doctors, respectively. For both malignant neoplasms and cardiac arrest 63% were direct admissions.

Conclusions

GPs or OOH doctors referred many emergencies to somatic hospitals, and for some clinical conditions GPs’ and OOH doctors’ gatekeeping role was substantial. However, a significant proportion of the emergency admissions was direct, and this reduces the impact of the GPs’ and OOH doctors’ gatekeeper roles, even in a strict gatekeeping system.

Performance of primary care in different healthcare facilities: a cross-sectional study of patients' experiences in Southern Malawi

OBJECTIVE

In most African countries, primary care is delivered through a district health system. Many factors, including staffing levels, staff experience, availability of equipment and facility management, affect the quality of primary care between and within countries. The purpose of this study was to assess the quality of primary care in different types of public health facilities in Southern Malawi.

STUDY DESIGN

This was a cross-sectional quantitative study.

SETTING

The study was conducted in 12 public primary care facilities in Neno, Blantyre and Thyolo districts in July 2018.

PARTICIPANTS

Patients aged ≥18 years, excluding the severely ill, were selected to participate in the study.

PRIMARY OUTCOMES

We used the Malawian primary care assessment tool to conduct face-to-face interviews. Analysis of variance at 0.05 significance level was performed to compare primary care dimension means and total primary care scores. Linear regression models at 95% CI were used to assess associations between primary care dimension scores, patients' characteristics and healthcare setting.

RESULTS

The final number of respondents was 962 representing 96.1% response rate. Patients in Neno hospitals scored 3.77 points higher than those in Thyolo health centres, and 2.87 higher than those in Blantyre health centres in total primary care performance. Primary care performance in health centres and in hospital clinics was similar in Neno (20.9 vs 19.0, p=0.608) while in Thyolo, it was higher at the hospital than at the health centres (19.9 vs 15.2, p<0.001). Urban and rural facilities showed a similar pattern of performance.

CONCLUSION

These results showed considerable variation in experiences among primary care users in the public health facilities in Malawi. Factors such as funding, policy and clinic-level interventions influence patients' reports of primary care performance. These factors should be further examined in longitudinal and experimental settings.

The effect of team collaboration and continuity of care on health and disability among rehabilitation patients: a longitudinal survey-based study from western Norway

PURPOSE

The purpose of this study was to investigate how changes in patient-rated health and disability from baseline to after rehabilitation were associated with communication and relationships in rehabilitation teams and patient-rated continuity of care.

METHODS

Linear models were used to assess the associations between relational coordination [RC] and Nijmegen Continuity Questionnaire-Norwegian version [NCQ-N] with changes in the World Health Association Disability Assessment Schedule 2.0 [WHODAS 2.0] and EuroQol EQ-VAS [EQ-VAS]. To express change in WHODAS 2.0 and EQ-VAS, the model was adjusted for WHODAS 2.0 and EQ-VAS baseline scores. Analyses for possible slopes for the various diagnosis groups were performed.

RESULTS

A sample of 701 patients were included in the patient cohort, followed from before rehabilitation to 1 year after a rehabilitation stay involving treatment by 15 different interprofessional teams. The analyses revealed associations between continuity of care and changes in patient-rated health, measured with EQ-VAS (all p values < 0.01). RC communication was associated with more improvement in functioning in neoplasms patient group, compared to improvement of health among included patient groups. The results revealed no associations between NCQ-N and WHODAS 2.0 global score, or between RC in the rehabilitation teams treating the patients and changes in WHODAS 2.0 global score.

CONCLUSION

The current results revealed that better personal, team and cross-boundary continuity of rehabilitation care was associated with better patient health after rehabilitation at 1-year follow-up. Measures of patient experiences with different types of continuity of care may provide a promising indicator of the quality of rehabilitation care.

Adolescents consulting general practitioners for psychological problems-a nationwide, register-based study in Norway

BACKGROUND

Psychological problems are increasing among adolescents, but little is known about the role of GPs in this area.

OBJECTIVES

This study aims to investigate the frequency of GP consultations with a psychological diagnosis in adolescence and predictors for such help seeking.

METHODS

Nationwide longitudinal register-based study investigating GP consultations among adolescents aged 13-17 years (N = 123 516) in Norway. First, all GP consultations within the study population were identified from the national GP claims register for 2006-11. Second, adolescents with a first-time consultation with a psychological diagnosis at age 15-16 years were identified, and prior GP consultations, prior somatic diagnoses, parental education and GP and GP-practice characteristics were assessed as possible predictors for seeking help.

RESULTS

From age 13 to 17 years, 15.3% of girls and 13.0% of boys had ≥1 GP consultation with a psychological diagnosis. In total, 6.8% of girls and 4.8% of boys consulted a GP for the first time with a psychological problem at age 15-16 years. For both sexes, number of prior GP consultations and a prior diagnosis of headache and abdominal pain predicted consulting with an internalizing problem (depression, anxiety and stress). A prior headache diagnosis predicted consulting for behavioural problems. Psychological diagnoses were more often found among adolescents with lower parental education. There were only minor associations with GP characteristics.

CONCLUSIONS

Norwegian adolescents often consult a GP and one in seven had a GP-diagnosed psychological problem at age 13-17. Policies to improve mental health care for adolescents should include strengthening of GP services.

Quality of primary care from patients' perspective: a cross sectional study of outpatients' experience in public health facilities in rural Malawi

BACKGROUND

Assessing patients' experience with primary care complements measures of clinical health outcomes in evaluating service performance. Measuring patients' experience and satisfaction are among Malawi's health sector strategic goals. The purpose of this study was to investigate patients' experience with primary care and to identify associated patients' sociodemographic, healthcare and health characteristics.

METHODS

This was a cross sectional survey using questionnaires administered in public primary care facilities in Neno district, Malawi. Data on patients' primary care experience and their sociodemographic, healthcare and health characteristics were collected through face to face interviews using a validated Malawian version of the primary care assessment tool (PCAT-Mw). Mean scores were derived for the following dimensions: first contact access, continuity of care, comprehensiveness, community orientation and total primary care. Linear regression models were used to assess association between primary care dimension scores and patients' characteristics.

RESULTS

From 631 completed questionnaires, first contact access, relational continuity and comprehensiveness of services available scored below the defined minimum. Sex, geographical location, self-rated health status, duration of contact with facility and facility affiliation were associated with patients' experience with primary care. These factors explained 10.9% of the variance in total primary care scores; 25.2% in comprehensiveness of services available and 29.4% in first contact access.

CONCLUSION

This paper presents results from the first use of the validated PCAT-Mw. The study provides a baseline indicating areas that need improvement. The results can also be used alongside clinical outcome studies to provide comprehensive evaluation of primary care performance in Malawi.

Relational coordination in interprofessional teams and its effect on patient-reported benefit and continuity of care: a prospective cohort study from rehabilitation centres in Western Norway

Background

Rehabilitation services depend on competent professionals who collaborate effectively. Well-functioning interprofessional teams are expected to positively impact continuity of care. Key factors in continuity of care are communication and collaboration among health care professionals in a team and their patients. This study assessed the associations between team functioning and patient-reported benefits and continuity of care in somatic rehabilitation centres.

Methods

This prospective cohort study uses survey data from 984 patients and from health care professionals in 15 teams in seven somatic rehabilitation centres in Western Norway. Linear mixed effect models were used to investigate associations between the interprofessional team communication and relationship scores (measured by the Relational Coordination [RC] Survey and patient-reported benefit and personal-, team- and cross-boundary continuity of care. Patient-reported continuity of care was measured using the Norwegian version of the Nijmegen Continuity Questionnaire.

Results

The mean communication score for healthcare teams was 3.9 (standard deviation [SD] = 0.63, 95% confidence interval [CI] = 3.78, 4.00), and the mean relationship score was 4.1 (SD = 0.56, 95% CI = 3.97, 4.18). Communication scores in rehabilitation teams varied from 3.4–4.3 and relationship scores from 3.6–4.5. Patients treated by teams with higher relationship scores experienced better continuity between health care professionals in the team at the rehabilitation centre (b = 0.36, 95% CI = 0.05, 0.68; p = 0.024). There was a positive association between RC communication in the team the patient was treated by and patient-reported activities of daily living benefit score; all other associations between RC scores and rehabilitation benefit scores were not significant.

Conclusion

Team function is associated with better patient-reported continuity of care and higher ADL-benefit scores among patients after rehabilitation. These findings indicate that interprofessional teams’ RC scores may predict rehabilitation outcomes, but further studies are needed before RC scores can be used as a quality indicator in somatic rehabilitation.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3536-5) contains supplementary material, which is available to authorized users.

GP-diagnosed internalizing and externalizing problems and dropout from secondary school: a cross-sectional study

Background

Dropout from secondary education is a major concern in many Western countries because it is associated with later adverse consequences at the individual and societal level. Efforts have thus been made to identify precursors for dropout. The aim of the study was to examine the risk for not finishing secondary education by age 20 when mental health problems were diagnosed during general practitioner (GP) consultations.

Methods

National registries were linked to assess the association between GP-diagnosed internalizing and externalizing problems from the ages of 15-20 years and school dropout in a sample of 63 970 Norwegians, adjusting for health and social background factors. Relative risks (RR) were estimated by Poisson regression.

Results

Dropout was bivariately related to both internalizing (RR = 2.2 among girls and 1.7 among boys) and externalizing problems (RR = 2.7 for girls and 2.0 for boys), though the associations were somewhat attenuated in the adjusted analyses. After controlling for somatic comorbidity and parent education level, the absolute risk for not fulfilling secondary education by age 20 was 43% among girls and 60% among boys with internalizing problems and approximately 15% points higher with externalizing problems. The highest absolute risk for dropout was found for boys and girls who have both externalizing and internalizing problems. However, with some overlap in the confidence intervals, the added impact of internalizing problems when added to externalizing problems is uncertain.

Conclusions

Intervention for mental health problems by a GP could benefit adolescent education outcomes and mental well-being.

Development and validation of a Malawian version of the primary care assessment tool

BACKGROUND

Malawi does not have validated tools for assessing primary care performance from patients' experience. The aim of this study was to develop a Malawian version of Primary Care Assessment Tool (PCAT-Mw) and to evaluate its reliability and validity in the assessment of the core primary care dimensions from adult patients' perspective in Malawi.

METHODS

A team of experts assessed the South African version of the primary care assessment tool (ZA-PCAT) for face and content validity. The adapted questionnaire underwent forward and backward translation and a pilot study. The tool was then used in an interviewer administered cross-sectional survey in Neno district, Malawi, to test validity and reliability. Exploratory factor analysis was performed on a random half of the sample to evaluate internal consistency, reliability and construct validity of items and scales. The identified constructs were then tested with confirmatory factor analysis. Likert scale assumption testing and descriptive statistics were done on the final factor structure. The PCAT-Mw was further tested for intra-rater and inter-rater reliability.

RESULTS

From the responses of 631 patients, a 29-item PCAT-Mw was constructed comprising seven multi-item scales, representing five primary care dimensions (first contact, continuity, comprehensiveness, coordination and community orientation). All the seven scales achieved good internal consistency, item-total correlations and construct validity. Cronbach's alpha coefficient ranged from 0.66 to 0.91. A satisfactory goodness of fit model was achieved (GFI = 0.90, CFI = 0.91, RMSEA = 0.05, PCLOSE = 0.65). The full range of possible scores was observed for all scales. Scaling assumptions tests were achieved for all except the two comprehensiveness scales. Intra-class correlation coefficient (ICC) was 0.90 (n = 44, 95% CI 0.81-0.94, p < 0.001) for intra-rater reliability and 0.84 (n = 42, 95% CI 0.71-0.96, p < 0.001) for inter-rater reliability.

CONCLUSIONS

Comprehensive metric analyses supported the reliability and validity of PCAT-Mw in assessing the core concepts of primary care from adult patients' experience. This tool could be used for health service research in primary care in Malawi.

Adolescent self-rated health predicts general practice attendance in adulthood: Results from the Young-HUNT1 survey

AIMS

Self-rated health (SRH) is a predictor of future health. However, the association between SRH in adolescence and health problems and health care utilization in adulthood has rarely been investigated. The aim of this study was to examine adolescent SRH as a predictor of general practitioner consultations in adulthood.

METHODS

SRH was registered in the Young-HUNT1 survey in 1995-1997 ( N=8828, mean age 16 years, 88% participation rate). General practitioner consultations during 2006-2014 were obtained from a national claims database. The predictive value of adolescent SRH on general practitioner consultations in adulthood was analysed by regression models estimating the relative risks (RR) for the total number of consultations and consultations for psychological, gastrointestinal, musculoskeletal or respiratory problems. Age, sex and baseline measures of chronic disease and health care attendance were used as the adjusting variables.

RESULTS

SRH was reported as 'very good' by 28.4%, 'good' by 60.6% and 'not good' by 11.0% of the respondents. The increases in consultation rates were 21% (RR 1.21, 95% CI 1.15-1.27) and 52% (RR 1.52, 95% CI 1.40-1.64) when comparing respondents with 'very good' SRH to those with 'good' and 'not good' SRH, respectively. We also demonstrated a dose-response association between adolescent SRH and general practitioner consultations for psychological, gastrointestinal, musculoskeletal or respiratory problems.

CONCLUSIONS

SRH in adolescence is a predictor for general practitioner consultations in adult life. Previous research shows that SRH is influenced by factors such as well-being, health behaviour, functional status and body satisfaction. Intervention studies are needed to evaluate whether population-based and clinical interventions can improve SRH by improving these factors among adolescents.

New episodes of musculoskeletal conditions among employed people in Norway, sickness certification and return to work: a multiregister-based cohort study from primary care

OBJECTIVES

To identify new cases of musculoskeletal (MSK) disorders among employed people presenting in Norwegian primary care in 2012, frequency of sickness certification and length of sick leave. To identify patient-, diagnosis- and GP-related predictors of sickness certification, prolonged sick leave and return to work (RTW).

METHODS

An observational multiregister-based cohort study covering all employed persons in Norway(1 176 681 women and 1 330 082 men) based on claims data from all regular GPs merged with individual sociodemographic data from public registers was performed. Participants were employed patients without any GP consultation during the previous 3 months who consulted a GP with a diagnosis of a MSK condition. Those not on sick leave and with a known GP affiliation were included in the analyses. Outcomes were incidence, proportion sickness certified and proportion on sick leave after 16 days, according to the diagnosis, ORs with 95% CIs for sickness certified and for sick leave exceeding 16 days and HRs with 95% CIs for RTW.

RESULTS

One-year incidence of MSK episodes was 159/1000 among employed women and 156/1000 among employed men. 27.1% of the women and 28.2% of the men were sickness certified in the initial consultation. After 16 days, 10.5% of women and 9.9% of men were still on sick leave. Upper limb problems were most frequent. After adjustments, medium/high education predicted a lower risk of absence from work due to sickness and rapid RTW after 16 days. Back pain, fractures and female gender carried a higher risk of sickness certification but faster RTW. Older age was associated with less initial certification, more sick leave exceeding 16 days and slower RTW. Male patients with male GPs had a lower risk of sickness absence, which was similar to patients with GPs born in Norway and GPs with many patients. After 16 days, GP variables had no effect on RTW.

CONCLUSION

Upper limb problems and GPs as stakeholders in 'the inclusive workplace' strategy need more attention.

Patient perspectives on continuity of care: adaption and preliminary psychometric assessment of a Norwegian version of the Nijmegen Continuity Questionnaire (NCQ-N)

Background

Continuity of care is regarded as a core quality element in healthcare. Continuity can be related to one or more specific caregivers but also applies to collaboration within a team or across boundaries of healthcare. Measuring continuity is important to identify problems and evaluate quality improvement of interventions.

This study aimed to assess the feasibility and psychometric properties of a Norwegian version of the Nijmegen Continuity Questionnaire (NCQ).

Methods

The NCQ was developed in The Netherlands. It measures patients’ experienced continuity of care across multiple care settings and as a multidimensional concept regardless of morbidity. The NCQ comprises 28 items categorised into three subscales; two personal continuity scales, “care giver knows me” and “shows commitment”, asked regarding the patient’s general practitioner (GP) and the most important specialist; and one “team/cross boundary continuity” scale, asked regarding primary care, specialised care and cooperation between GP and specialist, with a total of seven factors. The NCQ was translated and adapted to Norwegian (NCQ-N) and distributed among patients referred to somatic rehabilitation (N = 984, response rate 34.5%). Confirmatory factor analyses (CFA), Cronbach’s alpha, intra-class correlation (ICC) and Bland–Altman plots were used to assess psychometric properties.

Results

All patients (N = 375) who had responded to all parts of the NCQ-N were included in CFA. The CFA fit indices (CFI 0.941, RMSEA 0.064 (95% CI 0.059–0.070), SRMR 0.041) support a seven-factor structure in the NCQ-N based on the three subscales of the original NCQ. Cronbach’s alpha showed internal consistency (0.84–0.97), and was highest for the team/cross-boundary subscales. The NCQ-N showed overall high reliability with ICC 0.84–91 for personal continuity factors and 0.67–0.91 for team factors, with the lowest score for team continuity within primary care.

Conclusions

Psychometric assessment of the NCQ-N supports that this instrument, based on the three subscales of the original Dutch NCQ, captures the concept of “continuity of care” among adult patients with a variety of longstanding medical conditions who use healthcare on a regular basis. However, its usefulness among varied patient groups, including younger people, patients with acute disorders and individuals with mental health problems, should be further evaluated.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2706-1) contains supplementary material, which is available to authorized users.

GP consultations for common mental disorders and subsequent sickness certification: register-based study of the employed population in Norway

BACKGROUND

Challenges related to work are in focus when employed people with common mental disorders (CMDs) consult their GPs. Many become sickness certified and remain on sick leave over time.

OBJECTIVES

To investigate the frequency of new CMD episodes among employed patients in Norwegian general practice and subsequent sickness certification.

METHODS

Using a national claims register, employed persons with a new episode of CMD were included. Sickness certification, sick leave over 16 days and length of absences were identified. Patient- and GP-related predictors for the different outcomes were assessed by means of logistic regression.

RESULTS

During 1 year 2.6% of employed men and 4.2% of employed women consulted their GP with a new episode of CMD. Forty-five percent were sickness certified, and 24 percent were absent over 16 days. Thirty-eight percent had depression and 19% acute stress reaction, which carried the highest risk for initial sickness certification, 75%, though not for prolonged absence. Men and older patients had lower risk for sickness certification, but higher risk for long-term absence.

CONCLUSION

Better knowledge of factors at the workplace detrimental to mental health, and better treatment for depression and stress reactions might contribute to timely return of sickness absentees.

Point-of-care testing with CRP in primary care: a registry-based observational study from Norway

Background

Norwegian primary health care is maintained on the regular general practitioners (RGPs), GP’s contracted to the municipalities in a list patient system, working at daytime and at out-of-hours services (OOH services). Respiratory disease is most prevalent during OOH services, and in more than 50 % of the consultations, a CRP test is performed. Children in particular have a high consultation rate, and the CRP test is frequently conducted, but the contributing factors behind its frequent use are not known. This study compares the RGPs rate of CRP use at daytime and OOH in consultations with children and how this rate is influenced by characteristics of the RGPs.

Methods

A cross-sectional register study was conducted based on all (N = 2 552 600) electronic compensation claims from consultations with children ≤ 5 year during the period 2009–2011 from primary health care. Consultation rates and CRP use were estimated and analysed using descriptive methods. Being among the 20 % of RGPs with the highest rate of CRP use at daytime or OOH was an outcome measure in regression analyses using RGP-, and RGP list characteristics as explanatory variables.

Results

One third of all RGPs work regularly in OOH services, and they use CRP 1.42 times more frequently in consultations with children in OOH services than in daytime services even when the distribution of diagnosis according to ICPC-2 chapters is similar. Not being approved specialist, have a large number at their patient-lists but relatively few children on their list and a large number of consultations with children were significantly associated with frequent use of CRP in daytime services. The predictors for frequent CRP use in OOH services were being a young doctor, having many consultations with children during OOH and a frequent use of CRP in daytime services.

Conclusions

The increase in the frequency of CRP test use from daytime to OOH occurs in general for RGPs and for all most used diagnoses. The RGPs who use the CRP test most frequently in their daytime practice have the highest rate of CRP in OOH services.

Use of GP services by patients with schizophrenia: a national cross-sectional register-based study

Background

Reform of health services has given primary care facilities increased responsibility for patients with serious mental disorders (SMD). There has also been a growing awareness of the high somatic morbidity among SMD patients, an obvious challenge for general practitioners (GPs). The aim of this study was to assess the utilisation of GP services by patients with schizophrenia.

Methods

The Norwegian list patient system is based on fee-for-service (FFS). For each contact, the GPs send a claim to National Health Insurance detailing the diagnosis, the type of contact, procedures performed, and the personal identifier of the patient. In this study complete GP claims data from 2009 for schizophrenia patients aged 25–60 years were used to assess their utilisation of GP services. Regression models were used to measure the association between patient, GP and practice characteristics, with FFS per patient used as a measure of service utilisation. Data on patients with diabetes (DM) and population means were used for comparison.

Results

The mean annual consultation rate was 5.0 and mean FFS was 2,807 Norwegian Kroner (NOK) for patients diagnosed with schizophrenia. Only 17% had no GP consultation, 26.2% had one or two, 25.3% had three to five, and 16.1% more than five consultations. GPs participated in multidisciplinary meetings for 25.7% of these patients. In schizophrenia patients, co-morbid DM increased the FFS by NOK 1400, obstructive lung disease by NOK 1699, and cardiovascular disease by NOK 863. The FFS for schizophrenia patients who belonged to a GP practice with a high proportion of mental health-related consultations increased by NOK 115 per percent point increase in proportion of consultations. Patients with schizophrenia living in municipalities with < 10,000 inhabitants had a mean increase in FFS of NOK 1048 compared with patients living in municipalities with > 50,000 inhabitants. Diagnostic tests were equally or more frequent used among patients with schizophrenia and comorbid somatic conditions than among similar patients without a SMD.

Conclusion

This study showed that most patients diagnosed with schizophrenia had regular contact with their GP, providing opportunities for the GP to care for both mental and somatic health problems.

The regular general practitioner and sickness absence--a register-based study

BACKGROUND

Undertaking research on the role of regular GPs with regard to rates of sickness absence is methodologically challenging, and existing results show a wide divergence. We investigated how long-term sickness absence is affected by the characteristics of doctors and their patient lists.

MATERIAL AND METHODS

The study encompassed all those vocationally active residents of Oslo and Bergen in 2005-2006 who had the same regular GP throughout 2006 (N = 298,039). Encrypted data on sickness absence for each individual in 2006, as well their age, gender and level of education were merged with data on the regular GPs (N = 568) and their patient lists, and subsequently analysed with the aid of logistic regression. The outcome variable was at least one period of sickness absence which had been paid for by the Norwegian Labour and Welfare Administration (NLWA). The explanatory variables included the age, gender, list length and list status (open/closed) of the regular GPs, as well as variables that characterised the composition of the patient lists. The analyses were stratified by gender and controlled for individual age and education.

RESULTS

The age, gender and list length of the regular GPs were not associated with sickness absence paid for by the NLWA. The odds ratio for sickness absence > 16 days was reduced for both women and men when the list contained many highly educated patients, a high proportion of elderly people and few disability pensioners. Men on lists with a high proportion of men and lists with a high proportion of vocationally active patients also had lower odds rates for sickness absence > 16 days. Among women, the rate of sickness absence was lower for those on open lists than for those on closed lists.

INTERPRETATION

In addition to well-known individual factors, the study shows that the likelihood of sickness absence is affected by the socio-demographic composition of the patient list to which one belongs.

Personal continuity of care in Norwegian general practice: a national cross-sectional study

OBJECTIVE

Personal continuity is regarded as a core value in general practice. The aim of this study was to determine the level of personal continuity in Norwegian general practice. An investigation was made of the associations between high levels of personal continuity and patient, general practitioner (GP), and list characteristics.

DESIGN

Cross-sectional register-based study.

SETTING

Norwegian general practice in 2009.

SUBJECTS

3220 GPs and 3 725 998 patients on the GP lists.

MAIN OUTCOME MEASURES

The Usual Provider Continuity Index (UPC), which measures the proportion of consultations made by the usual GP, was estimated for patients and aggregated to the GP list level. GPs were grouped into quartiles based on the UPC. Being a GP with a UPC in the two highest quartiles (UPC ≥ 0.80) was the outcome in the statistical analyses.

STATISTICS

Poisson regression models were used to estimate relative risks (RR).

RESULTS

The overall UPC was 0.78, increasing gradually from 0.68 in patients < 15 years of age to 0.86 for patients ≥ 60 years of age, and from 0.75 to 0.83 for patients with < 3 annual consultations compared with patients with > 10 consultations. A UPC > 0.80 was associated with longer patient lists and high GP consultation rates. Working in municipalities with < 10 000 residents was negatively associated with a high UPC. The UPC level for GPs was associated with total utilization of GP consultations in the list populations.

CONCLUSION

Overall, the Norwegian goal of a personal GP has been achieved; however, there are substantial variations between GPs and lower UPCs among young patients and in smaller municipalities.

Norwegian GPs' participation in multidisciplinary meetings: a register-based study from 2007

Background

An increasing number of patients with chronic disorders and a more complex health service demand greater interdisciplinary collaboration in Primary Health Care. The aim of this study was therefore to identify factors related to general practitioners (GPs), their list populations and practice municipalities associated with a high rate of GP participation in multidisciplinary meetings (MDMs).

Methods

A national cross-sectional register-based study of Norwegian general practice was conducted, including data on all GPs in the Regular GP Scheme in 2007 (N = 3179). GPs were grouped into quartiles based on the annual number of MDMs per patient on their list, and the groups were compared using one-way analysis of variance. Binary logistic regression was used to analyse associations between high rates of participation and characteristics of the GP, their list population and practice municipality.

Results

On average, GPs attended 30 MDMs per year. The majority of the meetings concerned patients in the age groups 20-59 years. Psychological disorders were the motivation for 53% of the meetings. In a multivariate logistic regression model, the following characteristics predicted a high rate of MDM attendance: younger age of the GP, with an OR of 1.6 (95% CI 1.2-2.1) for GPs < 45 years, a short patient list, with an OR of 4.9 (3.2-7.5) for list sizes below 800 compared to lists ≥ 1600, higher proportion of psychological diagnosis in consultations (OR3.4 (2.6-4.4)) and a high MDM proportion with elderly patients (OR 4.1 (3.3-5.4)). Practising in municipalities with less than 10,000 inhabitants (OR 3.7 (2.8-4.9)) and a high proportion of disability pensioners (OR 1.6 (1.2-2.2)) or patients receiving social assistance (OR 2.2 (1.7-2.8)) also predicted high rates of meetings.

Conclusions

Psychological problems including substance addiction gave grounds for the majority of MDMs. GPs with a high proportion of consultations with such problems also participated more frequently in MDMs. List size was negatively associated with the rate of MDMs, while a more disadvantaged list population was positively associated. Working in smaller organisational units seemed to facilitate cooperation between different professionals. There may be a generation shift towards more frequent participation in interdisciplinary work among younger GPs.

Young people and their GP: a register-based study of 1717 Norwegian GPs

BACKGROUND

Internationally, there has been a call to improve the youth-friendliness of health services. In surveys, 60-90% of young people report having contact with a GP at least once a year. Regular contact with the GP can be assumed to be an indicator of a youth-friendly health service. The aim of the current study was to identify associations between a high consultation rate with young people (15-24 years) on the one hand and GP characteristics, patient list characteristics and practice profiling factors on the other.

METHODS

A cross-sectional national register-based study from 2002-04 in Norwegian general practice. Data on 1717 GPs, their practice populations and a sample of 316 773 consultations with young people were used to estimate differences between GPs, using one-way analysis of variance and logistic regression.

RESULTS

The mean annual consultation rate with young people was 1.4 (95% confidence interval 1.4-1.5) and 2.2 (2.1-2.2) for the age groups 15-19 and 20-24, respectively. List characteristics indicating free capacity-a shorter patient list, a growing patient list and a high access for persons not on the patient list-were associated with a high youth consultation rate. Young age of the GP, low educational level among the list population and a high rate of interdisciplinary activity by the GP were also associated with a high youth consultation rate.

CONCLUSIONS

GPs seem to assign especially low priority to young people when workload is high or free capacity low. Increased awareness of these mechanisms and greater interdisciplinary cooperation could increase the youth-friendliness of general practice.