Video consultation in general practice during COVID-19: a register-based study in Denmark

BACKGROUND

During the COVID-19 pandemic, general practices in Denmark rapidly introduced video consultations (VCs) to prevent viral transmission.

AIM

To study the use of VCs in daytime general practice by describing the rate of VCs, and the patient characteristics associated with having VCs.

DESIGN & SETTING

Register-based study of consultations in daytime general practice in Denmark.

METHOD

We included all consultations in daytime general practice from 1 January 2019-30 November 2021. We calculated the rate of video use and categorised the general practices into no, low, and high use. Logistic regression was used to calculate adjusted odds ratios (aOR) for having a VC for different patient characteristics when contacting a video-using practice, stratified for low- and high-using practices.

RESULTS

A total of 30 148 478 eligible consultations were conducted during the pandemic period. VCs were used mostly during the early stage pandemic period, declining to about 2% of all clinic consultations in the late-stage period. Patients having more VCs were young, had a long education, were employed, and lived in big cities. In low-using practices, native Danes and 'western' immigrants had higher odds of receiving a VC than 'non-western' immigrants, and patients with ≥2 comorbidities had lower odds than those without comorbidities.

CONCLUSION

Patients of a younger age, with long education, or employment had higher odds of receiving a VC, while patients of an older age and patients who had retired had lower odds. This difference in the access to VCs warrants further attention.

Use of Video in Telephone Triage in Out-of-Hours Primary Care: Register-Based Study

Background

Out-of-hours primary care (OOH-PC) is challenging due to high workloads, workforce shortages, and long waiting and transportation times for patients. Use of video enables triage professionals to visually assess patients, potentially ending more contacts in a telephone triage contact instead of referring patients to more resource-demanding clinic consultations or home visits. Thus, video use may help reduce use of health care resources in OOH-PC.

Objective

This study aimed to investigate video use in telephone triage contacts to OOH-PC in Denmark by studying rate of use and potential associations between video use and patient- and contact-related characteristics and between video use and triage outcomes and follow-up contacts. We hypothesized that video use could serve to reduce use of health care resources in OOH-PC.

Methods

This register-based study included all telephone triage contacts to OOH-PC in 4 of the 5 Danish regions from March 15, 2020, to December 1, 2021. We linked data from the OOH-PC electronic registration systems to national registers and identified telephone triage contacts with video use (video contact) and without video use (telephone contact). Calculating crude incidence rate ratios and adjusted incidence rate ratios (aIRRs), we investigated the association between patient- and contact-related characteristics and video contacts and measured the frequency of different triage outcomes and follow-up contacts after video contact compared to telephone contact.

Results

Of 2,900,566 identified telephone triage contacts to OOH-PC, 9.5% (n=275,203) were conducted as video contacts. The frequency of video contact was unevenly distributed across patient- and contact-related characteristics; it was used more often for employed young patients without comorbidities who contacted OOH-PC more than 4 hours before the opening hours of daytime general practice. Compared to telephone contacts, notably more video contacts ended with advice and self-care (aIRR 1.21, 95% CI 1.21-1.21) and no follow-up contact (aIRR 1.08, 95% CI 1.08-1.09).

Conclusions

This study supports our hypothesis that video contacts could reduce use of health care resources in OOH-PC. Video use lowered the frequency of referrals to a clinic consultation or a home visit and also lowered the frequency of follow-up contacts. However, the results could be biased due to confounding by indication, reflecting that triage GPs use video for a specific set of reasons for encounters.

Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark

BACKGROUND

Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice.

METHODS

We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression.

RESULTS

Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation.

CONCLUSION

The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.

Factors associated with undertriage and overtriage in telephone triage in Danish out-of-hours primary care: a natural quasi-experimental cross-sectional study of randomly selected and high-risk calls

OBJECTIVES

We aim to explore undertriage and overtriage in a high-risk patient population and explore patient characteristics and call characteristics associated with undertriage and overtriage in both randomly selected and in high-risk telephone calls to out-of-hours primary care (OOH-PC).

DESIGN

Natural quasi-experimental cross-sectional study.

SETTING

Two Danish OOH-PC services using different telephone triage models: a general practitioner cooperative with GP-led triage and the medical helpline 1813 with computerised decision support system-guided nurse-led triage.

PARTICIPANTS

We included audio-recorded telephone triage calls from 2016: 806 random calls and 405 high-risk calls (defined as patients ≥30 years calling with abdominal pain).

MAIN OUTCOME MEASURES

Twenty-four experienced physicians used a validated assessment tool to assess the accuracy of triage. We calculated the relative risk (RR) for clinically relevant undertriage and overtriage for a range of patient characteristics and call characteristics.

RESULTS

We included 806 randomly selected calls (44 clinically relevant undertriaged and 54 clinically relevant overtriaged) and 405 high-risk calls (32 undertriaged and 24 overtriaged). In high-risk calls, nurse-led triage was associated with significantly less undertriage (RR: 0.47, 95% CI 0.23 to 0.97) and more overtriage (RR: 3.93, 95% CI 1.50 to 10.33) compared with GP-led triage. In high-risk calls, the risk of undertriage was significantly higher for calls during nighttime (RR: 2.1, 95% CI 1.05 to 4.07). Undertriage tended to be more likely for calls concerning patients ≥60 years compared with 30-59 years (11.3% vs 6.3%) in high-risk calls. However, this result was not significant.

CONCLUSION

Nurse-led triage was associated with less undertriage and more overtriage compared with GP-led triage in high-risk calls. This study may suggest that to minimise undertriage, the triage professionals should pay extra attention when a call occurs during nighttime or concerns elderly. However, this needs confirmation in future studies.

Development over time in point-of-care test use in Danish daytime and out-of-hours general practice: a register-based study

OBJECTIVE

To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT).

DESIGN AND SETTINGS

A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018.

SUBJECTS

All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period.

MAIN OUTCOME MEASURES

We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use.

RESULTS

Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40-59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0-19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing.

CONCLUSION

The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40-59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

Interprofessional team-based collaboration between designated GPs and care home staff: a qualitative study in an urban Danish setting

BACKGROUND

Being a general practitioner for residents in many care homes may challenge communication with residents, relatives, and care home staff, and potentially lead to lower quality of care. Several countries have therefore introduced different solutions to reduce the number of general practitioners at each care home. In 2017, the designated general practitioner model was introduced at many Danish care homes. This study aimed to evaluate experiences from the interprofessional team-based collaboration between designated general practitioners and care home staff with regular contact with the designated general practitioners in an urban Danish setting.

METHODS

A qualitative design was applied using semi-structured interviews. Eight interviews (three group interviews and five individual interviews) were conducted with four designated general practitioners and seven care home staff members at four care homes in an urban setting of Central Denmark Region, Denmark. The interviews were transcribed verbatim, and data were analysed using content analysis with inspiration from the theory of relational coordination. The study followed the guidelines addressed in the COREQ (Consolidated Criteria for Reporting Qualitative Research) framework.

RESULTS

The initiation of the designated general practitioner model was experienced to contribute to more clear, precise, and timely communication between care homes and the general practitioner. An improved mutual acknowledgement of roles and competencies was experienced between designated general practitioners, care home nurses, and sometimes also social and health care assistants. The more frequent visits by the general practitioners at the care homes, as a result of the designated general practitioner model, resulted in more face-to-face communication between care home staff and designated general practitioners. Professional differences in the interpretation of the patient's needs were still present, which at times caused a frustrating compromise of own professional competencies. An important reason for the overall perception of improved collaboration was attributed to the more frequent dialogue in which the care homes staff and the designated general practitioners exchanged knowledge that could be applied in future patient encounters.

CONCLUSION

The designated general practitioner model implied an improved collaboration between general practitioners and care homes staff. Clear, precise, and timely communication between care homes and the general practitioners, as well as mutual trust and acknowledgement was experienced to be essential for the collaboration. An important reason for the overall perception of an improved collaboration was attributed to the more frequent dialogue (more frequent general practitioner visits at the care homes) in which the care homes staff and the designated general practitioners exchange knowledge which again could be applied in future patient encounters.

Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study

OBJECTIVE

To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates.

DESIGN

Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data.

SETTING

OOH primary care of the Central Denmark Region.

SUBJECTS

All patient contacts in 2014-2017.

MAIN OUTCOME MEASURES

GPs' tendency to prescribe antibiotics. Excess variation (not attributable to chance).

RESULTS

We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including 'activity level' (i.e. number of patients seen in the past hour) for clinic and telephone consultations, 'familiarity with OOH care' (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r²: 0.008-0.025).

CONCLUSION

Some variation in the GPs' tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs' activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners' activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.

Health care utilization related to the introduction of designated GPs at care homes in Denmark: a register-based study

OBJECTIVE

To investigate the correlation between having designated general practitioners (GPs) in residential care homes and the residents' number of contacts with primary care, number of hospital admissions and mortality.

DESIGN

A retrospective register-based longitudinal study.

SETTING

Forty-two care homes in Aarhus Municipality, Denmark.

SUBJECTS

A total of 2376 care home residents in the period from 1 September 2016 to 31 December 2018.

MAIN OUTCOME MEASURES

We used two models to calculate the incidence risk ratio (IRR) for primary care contacts, hospital admission or dying. Model 1 compared the residents' risk time before with their risk time after implementation of the designated GP model. Model 2 included only risk time after implementation and was based on calculations of successful (rate ≥60%) implementation.

RESULTS

Weighted by time at risk, the proportion of females across the two models ranged from 64% to 68%. The largest group was aged '85-94' years. In Model 1, the mere implementation of the model did not correlate with changes in primary care contacts, hospital admissions, or mortality. Contrarily, in Model 2, residents living in care homes with successful implementation had fewer email contacts (IRR = 0.81, 95%CI: 0.68;0.96), fewer telephone contacts (IRR = 0.78, 95%CI: 0.68;0.90) and fewer hospital admissions (IRR = 0.85, 95%CI: 0.73;0.99), but more home visits (IRR = 1.70, 95%CI: 1.29;2.25) than residents living in care homes with lower implementation rates.

CONCLUSION

The designated GP model seems promising, as a high implementation degree of the model correlated with a reduced the number of acute admissions, short-term admissions and readmissions. Future studies should focus on gaining deeper insight into the mechanisms of the designated GP model to further optimize the model.Key pointsA new care model was introduced in Denmark in 2017, designating dedicated GPs to residential care homes for the elderly.Successful implementation correlated with significantly fewer hospital admissions, specifically for acute admissions, but also with fewer short-term admissions and readmissions.The implementation of the model correlated significantly with fewer e-mail and telephone contacts and with more home visits.Future studies should gain more insight into the mechanisms of the designated GP model to further optimize the model.

The impact of a Danish stroke campaign: A cross-sectional study

OBJECTIVES

To investigate the impact of the Danish stroke campaign, 1 year after initiation.

MATERIALS & METHODS

The campaign ran in various media during 2019-2020. We performed a two-centre, repeated cross-sectional study in 2018 (before campaign) and again in 2020 based on data from structured interviews of patients and bystanders, medical records and the Danish Stroke Registry. Primary outcomes were patient delay and system delay. Patient delay is defined as the time from symptom onset until the first contact to a healthcare professional, whereas system delay is the time from this contact until arrival at the stroke centre. Secondary outcomes were primary emergency medical services (EMS) contact, arrival at a stroke centre within 3 h of symptom onset, initiation of reperfusion therapy and knowledge of ≥2 core symptoms of stroke.

RESULTS

We included 852 patients with stroke or transient ischemic attack. Patient delay and system delay were a median of 166 min and 96 min before the campaign and were non-significantly reduced by 16 min (95% CI -128 to 97) and 7 min (95% CI -21 to 6) in the second period. We found no significant differences in the clinical outcomes. The knowledge of ≥2 core symptoms increased from 22% to 30% (OR 1.63; 95% CI 1.15 to 2.30) in patients and from 53% to 65% (OR 1.81; 95% CI 1.24 to 2.64) in bystanders.

CONCLUSION

Patient delay, system delay and clinical outcomes remained relatively unchanged. However, the knowledge of core symptoms had improved 1 year after campaign initiation.

Antibiotic treatment of community-acquired pneumonia: A questionnaire survey in Danish general practice

BACKGROUND

Discrepancies exist in Danish guidelines for the treatment of bacterial community-acquired pneumonia (CAP). This study aimed to investigate how general practitioners (GPs) treat adults with CAP and explore associations between GP characteristics and treatment duration.

METHODS

In autumn 2020, GPs in the North Denmark Region were asked to complete an electronic questionnaire on antibiotic prescribing for CAP. Information about GP gender, age, experience and type of practice was obtained. Multivariable logistic regression was used to analyse the association between GP characteristics and treatment duration.

RESULTS

A total of 298 GPs were invited to participate of whom 108 completed the survey. Penicillin V was used as first line treatment for CAP by all participants. Treatment duration varied from 5 (54.6%) to 10 days (8.3%). A 5-day course of penicillin was less likely to be prescribed by male GPs (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13-0.94) and more likely to be prescribed by GPs with 5-9 years of experience in general practice (OR 5.03, 95% CI 1.09-23.21) compared to those with 10-19 years of experience.

CONCLUSION

Variation in antibiotic treatment of CAP emphasises the importance of generating solid evidence about the optimal duration regarding both effectiveness and safety.

Help-seeking behaviour and subsequent patient and system delays in stroke

OBJECTIVES

Prehospital delay is the main reason why only a limited number of stroke patients receive reperfusion therapy. We aimed to investigate help-seeking behaviour in patients and bystanders after onset of stroke and subsequent patient and system delay.

MATERIALS & METHODS

We conducted a cross-sectional study of 332 patients with stroke. We performed structured interviews and used data from the medical records and the Danish Stroke Registry. Primary outcomes were patient delay and system delay.

RESULTS

The median patient delay was 280 min, and the median system delay was 97 min. For a patient delay of <3 h, an additional non-significant system delay of median 30 min was seen for a first contact to a general practitioner (GP), and an additional significant delay of median 490 min was seen for the small group of patients with a first contact to 'other' healthcare professionals compared to the Emergency Medical Services (EMS). For a patient delay of more than 3 h, an additional system delay of median 78 min was found when the first contact was directed to the out-of-hours primary care (OOH-PC). A total of 17% of patients were admitted to another hospital or department before arrival at the stroke centre; this resulted in a substantially prolonged system delay of a median of 431 min.

CONCLUSIONS

Patient delay remains the main reason for delayed arrival at the stroke centre. Appropriate help-seeking behaviour and efficient pre-hospital triage are essential for reducing the prehospital delay and increasing the proportion of patients receiving reperfusion therapy.

Use of acute care services by adults with a migrant background: a secondary analysis of a EurOOHnet survey

BACKGROUND

High demands create pressure on acute care services, such as emergency medical services (EMS), emergency departments (ED) and out-of-hours primary care (OOH-PC) services. A variety of patient- and organisational factors have been discussed as reasons why especially non-western migrants more frequently contact an ED or OOH-PC service than native born. We aim to investigate whether persons with a non-western and western migrant background more often contact an acute care service than native born and how this relates to the number of contacts with their general practitioners (GPs). In addition, we aim to explore how possible differences in acute care use by migrants can be explained.

METHODS

We performed secondary analysis of data collected for the EurOOHnet survey on OOH help-seeking behaviour in Denmark, the Netherlands and Switzerland. Differences in self-reported acute care use (sum of number of contacts with OOH-PC, the ED and 1-1-2/1-4-4) between non-western and western migrants and native born were tested with a quasi Poisson regression analysis. Mediation analyses were performed to examine the impact of factors related to help-seeking on the relation between self-reported acute care use and migrant background.

RESULTS

Non-western migrants had more acute care contacts than native born (adjusted IRR 1.74, 95% CI 1.33-2.25), whereas no differences were found between western migrants and native born. Migrants who regularly contacted OOH-PC or the ED also regularly contacted their GP. Mediation analyses showed that the factors employment, anxiety, attitude towards use of OOH-PC and problems in accessing the own GP could partly explain the higher acute care use of non-western migrants.

CONCLUSION

The higher use of acute care services by non-western migrants compared with native born could partly be explained by feeling fewer barriers to contact these services, feeling more anxiety, more unemployment and problems making an appointment with the GP. Increasing awareness and improving GP access could help migrants in navigating the healthcare system.

Observation of Microcanonical Atom Number Fluctuations in a Bose-Einstein Condensate

Quantum systems are typically characterized by the inherent fluctuation of their physical observables. Despite this fundamental importance, the investigation of the fluctuations in interacting quantum systems at finite temperature continues to pose considerable theoretical and experimental challenges. Here we report the characterization of atom number fluctuations in weakly interacting Bose-Einstein condensates. Technical fluctuations are mitigated through a combination of nondestructive detection and active stabilization of the cooling sequence. We observe fluctuations reduced by 27% below the canonical expectation for a noninteracting gas, revealing the microcanonical nature of our system. The peak fluctuations have near linear scaling with atom number ΔN_{0,p}^{2}∝N^{1.134} in an experimentally accessible transition region outside the thermodynamic limit. Our experimental results thus set a benchmark for theoretical calculations under typical experimental conditions.

Who prescribes drugs to patients: A Danish register-based study

We describe the distribution of prescriber types responsible for issuing prescriptions in Denmark. Using a 20% random sample of all Danes alive during 2000–2018 (n = 1 515 025) and all their prescriptions filled at community pharmacies (n = 182 143 707), we found that general practitioners issued 88% of all prescriptions, followed by hospital physicians (7.4%) and private practicing specialists (4.2%). These values were stable over the study period. With increasing patient age, general practitioners were responsible for a larger proportion of prescriptions (e.g. 68% for patients aged 0–17 y and 89% for patients ≥51 y). General practitioners were responsible for 84% of all treatment initiation (first prescription) and 90% of all maintenance treatment. Corresponding values for hospital physicians were 9.5 and 6.3%, and for private practicing specialists 5.3 and 3.6%. In conclusion, general practitioners are responsible for the vast majority of prescribing in Denmark, including both treatment initiation and continuation, in particular among the elderly.

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

OBJECTIVE

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

DESIGN

Randomised controlled parallel superiority trial. Data from questionnaire survey.

SETTING

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

PARTICIPANTS

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

RANDOMISATION

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

INTERVENTION

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

MAIN OUTCOME MEASURES

Satisfaction and feeling of safety in callers.

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION DETAILS

NCT02572115 (5 October 2015).

Understanding the seriousness of a stroke is essential for appropriate help-seeking and early arrival at a stroke centre: A cross-sectional study of stroke patients and their bystanders

Introduction

Only a minority of patients with acute ischaemic stroke receive reperfusion treatment, primarily due to prehospital delay. We aimed to investigate predictors of a primary contact to the emergency medical services, arrival at stroke centre within 3 h of symptom onset and initiation of reperfusion therapy in patients with acute stroke.

Patients and methods

We conducted a cross-sectional study of consecutive patients with acute ischaemic stroke, intracerebral haemorrhage or transient ischaemic attack. Structured interviews of patients and bystanders were performed and combined with clinical information from the Danish Stroke Registry. Eligible patients were aged ≥18 years and were independent in activities of daily living before the stroke.

Results

We included 435 patients. Presence of a bystander at symptom onset and knowledge of ≥2 core symptoms of stroke were associated with a primary emergency medical services contact. Higher stroke severity and patients or bystanders perceiving the situation as very serious were associated with a primary emergency medical services contact (OR_patients 2.10; 95% CI 1.12-3.95 and OR_bystanders 22.60; 95% CI 4.98-102.67), <3 h from onset to arrival (OR_patients 3.01; 95% CI 1.46-6.21 and OR_bystanders 4.44; 95% CI 1.37-14.39) and initiation of reperfusion therapy (OR_patients 3.08; 95% CI 1.23-7.75 and OR_bystanders 4.70; 95% CI 1.14-19.5).Conclusion: Having a bystander, knowledge of ≥2 core symptoms and understanding that stroke is a serious event are associated with appropriate help-seeking behaviour, shorter prehospital delay and higher chance of reperfusion therapy in acute stroke patients.

Safety, efficiency and health-related quality of telephone triage conducted by general practitioners, nurses, or physicians in out-of-hours primary care: a quasi-experimental study using the Assessment of Quality in Telephone Triage (AQTT) to assess audio-recorded telephone calls

Background

To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities.

Methods

Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n = 423), nurses using CDSS (n = 430), or physicians with different medical specialities (n = 441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage.

Results

The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2 min 57 s, SD: 105 s) than nurses (mean: 4 min 44 s, SD: 168 s).

Conclusions

Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.

Sociodemographic Characteristics Associated with Contacts to Emergency Medical Services and Out-of-Hours Primary Care: An Observational Study of 2.3 Million Citizens

Background

Out-of-hours (OOH) health care services are often divided into emergency medical services (EMS) and OOH primary care (OOH-PC). EMS and many OOH-PC use telephone triage, yet the patient still makes the initial choice of contacting a service and which service. Sociodemographic characteristics are associated with help-seeking. Yet, differences in characteristics for EMS and OOH-PC patients have not been investigated in any large-scale cohort studies. Such knowledge may contribute to organizing OOH services to match patient needs. Thus, in this study we aimed to explore which sociodemographic patient characteristics were associated with utilizing OOH health care and to explore which sociodemographic characteristics were associated with EMS or OOH-PC contact.

Methods

A population-based observational cohort study of inhabitants in two regions (North Denmark Region and Capital Region of Copenhagen) with or without contact to OOH services during 2016 was conducted. Associations between sociodemographic characteristics and OOH contacts (and EMS versus OOH-PC contact) were evaluated by regression analyses.

Results

We identified 619,857 patients with OOH contact. Female sex (IRR=1.16 (95% CI: 1.16-1.17)), non-western ethnicity (IRR=1.02 (95% CI: 1.01-1.02)), living alone (IRR=1.08 (95% CI: 1.08-1.09)), age groups ≥81 years (IRR=2.00 (95% CI: 1.98-2.02)) and 0-18 years (IRR=1.66 (95% CI: 1.66-1.67)) and low income (IRR=1.41 (95% CI: 1.40-1.42)) were more likely to contact OOH health care compared to males, Danish ethnicity, citizens cohabitating, age 31-65 years and high income. Disability pensioners more often contacted OOH care (IRR=1.79 (95% CI: 1.77-1.81) compared to employees. Old age (≥81 years) (OR=3.21 (95% CI: 3.13-3.30)), receiving cash benefits (OR=2.45 (95% CI: 2.36-2.54)), low income (OR=1.76 (95% CI: 1.72-1.81)) and living alone (OR=1.40 (95% CI: 1.37-1.42)) were all associated with EMS contacts rather than OOH-PC contacts.

Conclusion

Several sociodemographic factors were associated with contacting a health care service outside office hours and with contacting EMS rather than OOH-PC. Old age, low income, low education and low socioeconomic status were of greatest importance.

Communication quality in telephone triage conducted by general practitioners, nurses or physicians: a quasi-experimental study using the AQTT to assess audio-recorded telephone calls to out-of-hours primary care in Denmark

OBJECTIVES

To compare the quality of communication in out-of-hours (OOH) telephone triage conducted by general practitioners (GPs), nurses using a computerised decision support system and physicians with different medical specialities, and to explore the association between communication quality and efficiency, length of call and the accuracy of telephone triage.

DESIGN

Natural quasi-experimental cross-sectional study.

SETTING

Two Danish OOH services using different telephone triage models: a GP cooperative and the medical helpline 1813.

PARTICIPANTS

1294 audio-recorded randomly selected OOH telephone triage calls from 2016 conducted by GPs (n=423), nurses using CDSS (n=430) and physicians with different medical specialities (n=441).

MAIN OUTCOME MEASURES

Twenty-four physicians assessed the calls. The panel used a validated assessment tool (Assessment of Quality in Telephone Triage, AQTT) to measure nine aspects of communication, overall perceived communication quality, efficiency and length of call.

RESULTS

The risk of poor quality was significantly higher in calls triaged by GPs compared with calls triaged by nurses regarding 'allowing the caller to describe the situation' (GP: 13.5% nurse: 9.8%), 'mastering questioning techniques' (GP: 27.4% nurse: 21.1%), 'summarising' (GP: 33.0% nurse: 21.0%) and 'paying attention to caller's experience' (GP: 25.7% nurse: 17.0%). The risk of poor quality was significantly higher in calls triaged by physicians compared with calls triaged by GPs in five out of nine items. GP calls were significantly shorter (2 min 57 s) than nurse calls (4 min 44 s) and physician calls (4 min 1 s). Undertriaged calls were rated lower than optimally triaged calls for overall quality of communication (p<0.001) and all specific items.

CONCLUSIONS

Compared with telephone triage by GPs, the communication quality was higher in calls triaged by nurses and lower in calls triaged by physicians with different medical specialities. However, calls triaged by nurses and physicians were longer and perceived less efficient. Quality of communication was associated with accurate triage.

Acute care pathways for patients calling the out-of-hours services

BACKGROUND

In Western countries, patients with acute illness or injury out-of-hours (OOH) can call either emergency medical services (EMS) for emergencies or primary care services (OOH-PC) in less urgent situations. Callers initially choose which service to contact; whether this choice reflect the intended differences in urgency and severity is unknown. Hospital diagnoses and admission rates following an OOH service contact could elucidate this. We aimed to investigate and compare the prevalence of patient contacts, subsequent hospital contacts, and the age-related pattern of hospital diagnoses following an out-of-hours contact to EMS or OOH-PC services in Denmark.

METHODS

Population-based observational cohort study including patients from two Danish regions with contact to EMS or OOH-PC in 2016. Hospital contacts were defined as short (< 24 h) or admissions (≥24 h) on the date of OOH service contact. Both regions have EMS, whereas the North Denmark Region has a general practitioner cooperative (GPC) as OOH-PC service and the Capital Region of Copenhagen the Medical Helpline 1813 (MH-1813), together representing all Danish OOH service types. Calling an OOH service is mandatory prior to a hospital contact outside office hours.

RESULTS

OOH-PC handled 91% (1,107,297) of all contacts (1,219,963). Subsequent hospital contacts were most frequent for EMS contacts (46-54%) followed by MH-1813 (41%) and GPC contacts (9%). EMS had more admissions (52-56%) than OOH-PC. For both EMS and OOH-PC, short hospital contacts often concerned injuries (32-63%) and non-specific diagnoses (20-45%). The proportion of circulatory disease was almost twice as large following EMS (13-17%) compared to OOH-PC (7-9%) in admitted patients, whereas respiratory diseases (11-14%), injuries (15-22%) and non-specific symptoms (22-29%) were more equally distributed. Generally, admitted patients were older.

CONCLUSIONS

EMS contacts were fewer, but with a higher percentage of hospital contacts, admissions and prevalence of circulatory diseases compared to OOH-PC, perhaps indicating that patients more often contact EMS in case of severe disease. However, hospital diagnoses only elucidate severity of diseases to some extent, and other measures of severity could be considered in future studies. Moreover, the socio-demographic pattern of patients calling OOH needs exploration as this may play an important role in choice of entrance.

Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes

BACKGROUND

Out-of-hours (OOH) healthcare services in Western countries are often differentiated into out-of-hours primary healthcare services (OOH-PC) and emergency medical services (EMS). Call waiting time, triage model and intended aims differ between these services. Consequently, the care pathway and outcome could vary based on the choice of entrance to the healthcare system. We aimed to investigate patient pathways and 1- and 1-30-day mortality, intensive care unit (ICU) stay and length of hospital stay for patients with acute myocardial infarction (AMI), stroke and sepsis in relation to the OOH service that was contacted prior to the hospital contact.

METHODS

Population-based observational cohort study during 2016 including adult patients from two Danish regions with an OOH service contact on the date of hospital contact. Patients <18 years were excluded. Data was retrieved from OOH service databases and national registries, linked by a unique personal identification number. Crude and adjusted logistic regression analyses were performed to assess mortality in relation to contacted OOH service with OOH-PC as the reference and cox regression analysis to assess risk of ICU stay.

RESULTS

We included 6826 patients. AMI and stroke patients more often contacted EMS (52.1 and 54.1%), whereas sepsis patients predominately called OOH-PC (66.9%). Less than 10% (all diagnoses) of patients contacted both OOH-PC & EMS. Stroke patients with EMS or OOH-PC & EMS contacts had higher likelihood of 1- and 1-30-day mortality, in particular 1-day (EMS: OR = 5.33, 95% CI: 2.82-10.08; OOH-PC & EMS: OR = 3.09, 95% CI: 1.06-9.01). Sepsis patients with EMS or OOH-PC & EMS contacts also had higher likelihood of 1-day mortality (EMS: OR = 2.22, 95% CI: 1.40-3.51; OOH-PC & EMS: OR = 2.86, 95% CI: 1.56-5.23) and 1-30-day mortality. Risk of ICU stay was only significantly higher for stroke patients contacting EMS (EMS: HR = 2.38, 95% CI: 1.51-3.75). Stroke and sepsis patients with EMS contact had longer hospital stays.

CONCLUSIONS

More patients contacted OOH-PC than EMS. Sepsis and stroke patients contacting EMS solely or OOH-PC & EMS had higher likelihood of 1- and 1-30-day mortality during the subsequent hospital contact. Our results suggest that patients contacting EMS are more severely ill, however OOH-PC is still often used for time-critical conditions.

Communicative characteristics of general practitioner-led and nurse-led telephone triage at two Danish out-of-hours services: an observational study of 200 recorded calls

OBJECTIVES

Out-of-hours (OOH) telephone triage is used to manage patient flow, but knowledge of the communicative skills of telephone triagists is limited. The aims of this study were to compare communicative parameters in general practitioner (GP)-led and nurse-led OOH telephone triage and to discuss differences in relation to patient-centred communication and safety issues.

DESIGN

Observational study.

SETTING

Two Danish OOH settings: a large-scale general practitioner cooperative in the Central Denmark Region (n=100 GP-led triage conversations) and Medical Helpline 1813 in the Capital Region of Denmark (n=100 nurse-led triage conversations with use of a clinical decision support system).

PARTICIPANTS

200 audio-recorded telephone triage conversations randomly selected.

PRIMARY AND SECONDARY OUTCOME MEASURES

Conversations were compared with regard to length of call, distribution of speaking time, question types, callers' expression of negative affect, and nurses' and GPs' responses to callers' negative affectivity using the Mann-Whitney U test and the Student's t-test.

RESULTS

Compared with GPs, nurses had longer telephone contacts (137s vs 264 s, p=0.001) and asked significantly more questions (5 vs 9 questions, p=0.001). In 36% of nurse-led triage conversations, triage nurses either transferred the call to a physician or had to confer the call with a physician. Nurses gave the callers significantly more spontaneous talking time than GPs (23.4s vs 17.9 s, p=0.01). Compared with nurses, GPs seemed more likely to give an emphatic response when a caller spontaneously expressed concern; however, this difference was not statistically significant (36% vs 29%, p=0.6).

CONCLUSIONS

When comparing communicative parameters in GP-led and nurse-led triage, several differences were observed. However, the impact of these differences in the perspective of patient-centred communication and safety needs further research. More knowledge is needed to determine what characterises good quality in telephone triage communication.

Observation of Atom Number Fluctuations in a Bose-Einstein Condensate

Fluctuations are a key property of both classical and quantum systems. While the fluctuations are well understood for many quantum systems at zero temperature, the case of an interacting quantum system at finite temperature still poses numerous challenges. Despite intense theoretical investigations of atom number fluctuations in Bose-Einstein condensates, their amplitude in experimentally relevant interacting systems is still not fully understood. Moreover, technical limitations have prevented their experimental investigation to date. Here we report the observation of these fluctuations. Our experiments are based on a stabilization technique, which allows for the preparation of ultracold thermal clouds at the shot noise level, thereby eliminating numerous technical noise sources. Furthermore, we make use of the correlations established by the evaporative cooling process to precisely determine the fluctuations and the sample temperature. This allows us to observe a telltale signature: the sudden increase in fluctuations of the condensate atom number close to the critical temperature.

Preschool children in Danish out-of-hours primary care: a one-year descriptive study of face-to-face consultations

BACKGROUND

The demand for out-of-hours (OOH) primary care has increased during the last decades, with a considerable amount of contacts for young children. This study aims to describe the reasons for encounter (RFE), the most common diagnoses, the provided care, and the parental satisfaction with the general practitioner (GP) led OOH service in a Danish population of children (0-5 years).

METHODS

We conducted a one-year cross-sectional study based on data for 2363 randomly selected contacts concerning children from a survey on OOH primary care including 21,457 patients in Denmark. For each contact, the GPs completed an electronic pop-up questionnaire in the patient's medical record. Questionnaire items focussed on RFE, health problem severity, diagnosis, provided care, and satisfaction. The parents subsequently received a postal questionnaire.

RESULTS

The most common RFE was non-specific complaints (40%), followed by respiratory tract symptoms (23%), skin symptoms (9%), and digestive organ symptoms (8%). The most common diagnosis group was respiratory tract diseases (41%), followed by general complaints (19%) and ear diseases (16%). Prescriptions were dispensed for 27% of contacts, and about ¾ were for antibiotics. A total of 12% contacts concerned acute otitis media; antibiotics were prescribed in 70%. A total of 38% of contacts concerned fever, and ¼ got antibiotics. A total of 7.4% were referred for further evaluation. The parental satisfaction was generally high, but 7.0% were dissatisfied. Dissatisfaction was correlated with low prescription rate.

CONCLUSION

Respiratory tract diseases were the most common diagnoses. The GPs at the OOH primary care service referred children to hospital in 7.4% of the face-to-face consultations, and the provided care was evaluated as non-satisfying by only 7.0% of the parents. Clinical implications of the findings mean room for less prescription of antibiotic to children with ear diseases and a need for research in factors related to dissatisfaction.

Factors related to out-of-hours help-seeking for acute health problems: a survey study using case scenarios

Background

The acute out-of-hours healthcare services are challenged by increasing demand in many countries. We aimed to examine factors influencing the intended help-seeking in out-of-hours care for acute health problems during evenings, nights, and weekends.

Methods

We conducted a survey study based on data from parents of children (aged 0–4 years) and adults (aged 30–39 and 50–59 years) in Denmark, the Netherlands and Switzerland. Intended help-seeking behaviour was measured by six hypothetical case scenarios. We used Andersen’s Behavioural Model to categorise potentially influential factors and applied multiple binomial regression to assess the influence of selected factors.

Results

A total of 1015 parents and 2942 adults participated. We identified several significant influential factors. Parents holding a low education (OR 1.56), having migrant background (western: OR 1.23; non-western: OR 1.93), having one child (OR 1.24), perceiving few barriers to using out-of-hours primary care (OR 1.59), perceiving difficulties with organising childcare (OR 1.13), and having a history of frequent contacts with out-of-hours care (OR 1.55) were more inclined to contact out-of-hours care, whereas female (OR 0.85) and non-anxious parents (OR 0.77) were less inclined. Adults who were older (OR 1.01), holding a medical education (OR 1.13), having non-western background (OR 1.28), being unemployed (OR 1.17), perceiving few barriers to using out-of-hours primary care (OR 1.37), and having a history of frequent contacts with a GP (few: OR 1.15; more: OR 1.22) and/or with out-of-hours care (one: OR 1.20; more: OR 1.49) were more inclined to contact out-of-hours care, whereas adults with no or little social support (OR 0.84) and adults with high health literacy level on health information (OR 0.91) were less inclined. Dutch parents were less inclined than Danish parents to contact out-of-hours care (OR 0.62), whereas Swiss adults were more inclined than Danish adults to contact out-of-hours care (OR 1.16).

Conclusion

We identified several factors related to intended help-seeking in out-of-hours care. These results could be used to develop targeted interventions, but more research is needed to examine the underlying explanations for the identified differences.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6332-6) contains supplementary material, which is available to authorized users.

Impact of alternative healthcare plans on out-of-hours help-seeking intentions in Switzerland

INTRODUCTION

In Switzerland, mandatory health insurance plans (standard) offer free access to secondary and emergency care. However, in return for a lower premium, individuals can choose alternative healthcare plans (HCPs), with either a general practitioner (GP) or a medical call centre (Telmed) acting as gatekeeper.

AIM

To examine the impact of alternative HCPs on patients' intended help-seeking behaviour out-of-hours (OOH) in Switzerland.

METHODS

A secondary analysis of the Swiss data collected for the EurOOHnet survey on help-seeking behaviour in Denmark, the Netherlands and Switzerland was made. The survey used hypothetical scenarios for measuring two outcome measures: intended help-seeking for (1) OOH care and (2) OOH face-to-face care. Binomial regression analyses were used to test the influence of HCPs on intended OOH help-seeking, adjusted for other (population) characteristics.

RESULTS

Telmed-insured persons were more inclined to OOH help-seeking than persons with a standard HCP (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.91-2.72; controlled for other population factors), mainly driven by contact with the medical call centre (31 vs 5%), and were less inclined to have an OOH face-to-face contact (OR 0.69, 95% CI 0.55-0.87). Persons with a GP HCP had a lower intended use of face-to-face OOH care contacts than persons with a standard plan (OR 0.74, 95% CI 0.63-0.86).

CONCLUSION

Alternative HCPs on a voluntary basis seem to influence the use of OOH care. These results could be relevant for policy makers, especially from non-gatekeeping countries, to reduce irrelevant use and subsequent costs of emergency and OOH care services.

Help-seeking behaviour outside office hours in Denmark, the Netherlands and Switzerland: a questionnaire study exploring responses to hypothetical cases

OBJECTIVES

We aim to study the preferred behaviour among individuals from different age groups in three countries when acute health problems occur outside office hours and thereby to explore variations in help-seeking behaviour.

DESIGN

A questionnaire study exploring responses to six hypothetical cases describing situations with a potential need for seeking medical care and questions on background characteristics.

SETTING

General population in Denmark, the Netherlands and Switzerland.

POPULATION

Danish, Dutch and Swiss individuals from three age groups (0-4, 30-39, 50-59 years).

MAIN OUTCOME MEASURES

Distribution of intended help-seeking preferences per case per age group, compared between countries. Differences in percentage of help-seeking outside office hours per age group and country, crude and adjusted for background characteristics.

RESULTS

Danish and Dutch parents of children aged 0-4 years differed in intended help-seeking behaviour for five out of six cases (abdominal pain, red eyes, rash, relapse fever, chickenpox); Danish parents significantly more often chose to contact out-of-hours (OOH) care than Dutch parents. For adults aged 30-39 years, no significant difference between the three countries was found for contacting OOH care. Swiss adults aged 50-59 years had the highest percentage of OOH contacts (38.3%), followed by the Danish (33.4%) and the Dutch (32.5%).

CONCLUSION

Some differences in help-seeking behaviour outside office hours exist between Danish, Dutch and Swiss individuals, particularly for parents of young children. The question remains whether these differences result from individual preferences, cultural disparities and/or health services variations. Future research should focus on identifying explanations for these differences to reduce undesirable use of OOH care.

Cardiovascular effects of antidiabetic drugs

Type 2 diabetes mellitus is a common and severe chronic metabolic disease, which confers increased risk of cardiovascular disease and mortality. During the last decade a large number of new drugs within the classes dipeptidyl peptidase 4 (DPP-4) inhibitors (DPP-4Is), glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1RAs) and sodium/glucose cotransporter 2 (SGLT-2) inhibitors (SGLT-2Is) have been developed and tested in nine large-scale cardiovascular outcome trials (CVOTs). Here we review the evidence behind antihyperglycemic treatment of patients with type 2 diabetes with a particular focus on compiling and summarizing the evidence of hard clinical endpoints stemming from these large CVOTs.

Paper- or Web-Based Questionnaire Invitations as a Method for Data Collection: Cross-Sectional Comparative Study of Differences in Response Rate, Completeness of Data, and Financial Cost

Background

Paper questionnaires have traditionally been the first choice for data collection in research. However, declining response rates over the past decade have increased the risk of selection bias in cross-sectional studies. The growing use of the Internet offers new ways of collecting data, but trials using Web-based questionnaires have so far seen mixed results. A secure, online digital mailbox (e-Boks) linked to a civil registration number became mandatory for all Danish citizens in 2014 (exemption granted only in extraordinary cases). Approximately 89% of the Danish population have a digital mailbox, which is used for correspondence with public authorities.

Objective

We aimed to compare response rates, completeness of data, and financial costs for different invitation methods: traditional surface mail and digital mail.

Methods

We designed a cross-sectional comparative study. An invitation to participate in a survey on help-seeking behavior in out-of-hours care was sent to two groups of randomly selected citizens from age groups 30-39 and 50-59 years and parents to those aged 0-4 years using either traditional surface mail (paper group) or digital mail sent to a secure online mailbox (digital group). Costs per respondent were measured by adding up all costs for handling, dispatch, printing, and work salary and then dividing the total figure by the number of respondents. Data completeness was assessed by comparing the number of missing values between the two methods. Socioeconomic variables (age, gender, family income, education duration, immigrant status, and job status) were compared both between respondents and nonrespondents and within these groups to evaluate the degree of selection bias.

Results

A total 3600 citizens were invited in each group; 1303 (36.29%) responded to the digital invitation and 1653 (45.99%) to the paper invitation (difference 9.66%, 95% CI 7.40-11.92). The costs were €1.51 per respondent for the digital group and €15.67 for paper group respondents. Paper questionnaires generally had more missing values; this was significant in five of 17 variables (P<.05). Substantial differences were found in the socioeconomic variables between respondents and nonrespondents, whereas only minor differences were seen within the groups of respondents and nonrespondents.

Conclusions

Although we found lower response rates for Web-based invitations, this solution was more cost-effective (by a factor of 10) and had slightly lower numbers of missing values than questionnaires sent with paper invitations. Analyses of socioeconomic variables showed almost no difference between nonrespondents in both groups, which could imply that the lower response rate in the digital group does not necessarily increase the level of selection bias. Invitations to questionnaire studies via digital mail may be an excellent option for collecting research data in the future. This study may serve as the foundational pillar of digital data collection in health care research in Scandinavia and other countries considering implementing similar systems.

Factors associated with low patient satisfaction in out-of-hours primary care in Denmark - a population-based cross-sectional study

BACKGROUND

Low patient satisfaction with the quality of out-of-hours primary care (OOH-PC) has been linked with several individual and organizational factors. However, findings have been ambiguous and may not apply to the Danish out-of-hours (OOH) setting in which general practitioners (GPs) perform the initial telephone triage. This study aimed to identify patient-related, GP-related and organizational factors associated with low patient satisfaction.

METHODS

The study was based on data from a 1-year population-based survey of OOH-PC (LV-KOS) in the Central Denmark Region in 2010-2011. GPs on OOH duty completed an electronic questionnaire in the OOH computer system, and the registered patients received a subsequent postal questionnaire focusing on contact evaluation, waiting time, demographic characteristics and general self-perceived health. Associations were analysed using multivariable logistic regression with dissatisfaction as the dependent variable.

RESULTS

The patient response rate was 50.6%. For all contact types, 82.5% of the patients were satisfied with the OOH-PC service. More patients were dissatisfied with telephone consultations than with clinic consultations or home visits (8.5% vs. 6.0% and 4.3%, respectively). Contacts assessed by the GP as 'not severe' were associated with dissatisfaction for telephone consultations and home visits. Poor general self-perceived health was associated with dissatisfaction for all contact types. Living in urban areas was associated with dissatisfaction for telephone consultations, while unacceptable waiting time was associated with dissatisfaction for all contact types.

CONCLUSIONS

We found a high level of patient satisfaction with the OOH-PC service. The only factors affecting patient satisfaction across all contact types were unacceptable waiting time and poor general self-perceived health. For the other investigated factors, patient satisfaction depended on the type of contact. Generally, patients contacting for GP-assessed non-severe health problem and patients living in urban areas were more dissatisfied.

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

Background

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

Methods

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

Results

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

Conclusions

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

Mesenchymal stromal cell injection promotes vocal fold scar repair without long-term engraftment

BACKGROUND

Regenerative medicine holds promise for restoring voice in patients with vocal fold scarring. As experimental treatments approach clinical translation, several considerations remain. Our objective was to evaluate efficacy and biocompatibility of four bone marrow mesenchymal stromal cell (BM-MSC) and tunable hyaluronic acid based hydrogel (HyStem-VF) treatments for vocal fold scar using clinically acceptable materials, a preclinical sample size and a dosing comparison.

METHODS

Vocal folds of 84 rabbits were injured and injected with four treatment variations (BM-MSC, HyStem-VF, and BM-MSC in HyStem-VF at two concentrations) 6 weeks later. Efficacy was assessed with rheometry, real-time polymerase chain reaction (RT-PCR) and histology at 2, 4 and 10 weeks following treatment. Lung, liver, kidney, spleen and vocal folds were screened for biocompatibility by a pathologist.

RESULTS AND DISCUSSION

Persistent inflammation was identified in all hydrogel-injected groups. The BM-MSC alone treatment appeared to be the most efficacious and safe, providing an early resolution of viscoelasticity, gene expression consistent with desirable extracellular matrix remodeling (less fibronectin, collagen 1α2, collagen 3, procollagen, transforming growth factor [TGF]β1, alpha smooth muscle actin, interleukin-1β, interleukin-17β and tumor necrosis factor [TNF] than injured controls) and minimal inflammation. Human beta actin expression in BM-MSC-treated vocal folds was minimal after 2 weeks, suggesting that paracrine signaling from the BM-MSCs may have facilitated tissue repair.

Development and evaluation of an "emergency access button" in Danish out-of-hours primary care: a study protocol of a randomized controlled trial

BACKGROUND

Out-of-hours (OOH) health care for acute medical problems is often challenged by long waiting time for callers in need of advice and triage. Allowing patients to bypass the OOH telephone waiting line may increase patient satisfaction and provide them with a feeling of safety. We aimed to develop an "emergency access button" enabling patients to bypass the normal telephone waiting line in out-of-hours primary care (OOH-PC) if they perceive their condition to be critical and to evaluate the effect of introducing the button in terms of patient satisfaction and their feeling of safety.

METHODS

All patients calling the OOH-PC in two different Danish health care regions during three months will be included in this randomized controlled trial. Data will be collected through two questionnaires developed for this study: a pop-up questionnaire on the relevance of bypassing the normal waiting line to be completed by triage professionals after patient contact and a paper/electronic questionnaire on perceived safety and satisfaction with the emergency access button to be completed by the callers. These questionnaires were developed and validated using external and internal expert feedback, focus group interviews and a two-week field test. The study will be conducted over three months with an estimated user-rate of the emergency access button of 3%.

DISCUSSION

We have developed an emergency access button and we now want to investigate whether this new option will influence upon the level of satisfaction and the feeling of safety in the calling patients. Additionally, the study will reveal the assessed relevance of the decision to bypass the line by triage professionals.

TRIAL REGISTRATION

Registered as NCT02572115 at Clinicaltrials.gov on October 5^th 2015.

The Utility of Acute-Phase Proteins in the Assessment of Treatment Response in Dogs With Bacterial Pneumonia

Background

Acute‐phase proteins (APPs) are sensitive markers of inflammation, and serum C‐reactive protein (CRP) recently has been shown to be a useful diagnostic marker in dogs with bacterial pneumonia (BP). In humans with community‐acquired pneumonia, APPs also have great utility as follow‐up markers aiding in the assessment of treatment response.

Objectives

The aim of our study was to investigate the applicability of APPs as markers of treatment response in dogs with BP.

Animals

Nineteen dogs diagnosed with BP and 64 healthy dogs.

Methods

The study was conducted as a prospective longitudinal observational study. Serum CRP, serum amyloid A (SAA), and haptoglobin concentrations were followed during a natural course of BP. Normalization of serum CRP was used to guide the duration of antibiotic treatment (treatment was stopped 5–7 days after CRP normalized) in 8 of 17 dogs surviving to discharge; 9 of 17 dogs were treated according to conventional recommendations.

Results

All measured APPs initially were significantly increased, but the magnitude of increase was not correlated to disease severity. C‐reactive protein and SAA concentrations decreased rapidly after initiation of antimicrobial treatment. When normalization of serum CRP was used to guide the duration of antibiotic treatment, treatment duration was significantly (P = .015) decreased without increasing the number of relapses.

Conclusions and Clinical Importance

Serum CRP and SAA reflected the recovery process well and therefore may be used as markers of treatment response. According to the results, the normalization of serum CRP may be used to guide the duration of antibiotic treatment in dogs with BP.

Drug prescriptions in Danish out-of-hours primary care: a 1-yearpopulation-based study

OBJECTIVE

General practitioners are the first point of contact in Danish out-of-hours (OOH) primary care. The large number of contacts implies that prescribing behaviour may have considerable impact on health-care expenditures and quality of care. The aim of this study was to examine the prevailing practices for medication prescription in Danish OOH with a particular focus on patient characteristics and contact type.

DESIGN AND SETTING

A one-year population-based retrospective observational study was performed of all contacts to OOH primary care in the Central Denmark Region using registry data.

MAIN OUTCOME MEASURES

Prescriptions were categorised according to Anatomical Therapeutic Chemical Classification (ATC) codes and stratified for patient age, gender and contact type (telephone consultation, clinic consultation or home visit). Prescription rates were calculated as number of prescriptions per 100 contacts.

RESULTS

Of 644,777 contacts, 154,668 (24.0%) involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits. Around 53% of all drug prescriptions were made in telephone consultations. Anti-infective medications for systemic use accounted for 45.5% of all prescriptions and were the most frequently prescribed drug group for all contact types, although accounting for less than 1/3 of telephone prescriptions. Other frequently prescribed drugs were ophthalmological anti-infectives (10.5%), NSAIDs (6.4%), opioids (3.9%), adrenergic inhalants (3.0%) and antihistamines (2.3%).

CONCLUSION

About 25% of all OOH contacts involved one or more medication prescriptions. The highest prescription rate was found for clinic consultations, but more than half of all prescriptions were made by telephone. KEY POINTS As the out-of-hours (OOH) primary care services cover more than 75% of all hours during a normal week, insight into the extent and type of OOH drug prescription is important. General practitioners (GPs) are responsible for more than 80% of all drug prescriptions in Denmark. Of all contacts 24.0% involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits. Of all prescriptions, 53% were made in telephone consultations. Anti-infective medications for systemic use accounted for 45.5% of all prescriptions, thereby being the most frequently prescribed drug group for all three contact types.

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

BACKGROUND

GPs answer all patient calls to the out-of-hours primary care (OOH-PC) services in Denmark. Knowledge is scarce on how the triage-GPs act on the specific reasons for encounter (RFE).

OBJECTIVE

This study aims to describe the RFEs, the applied diagnoses and the severity of health problems presented in calls to the OOH-PC.

METHODS

This was a 1-year cross-sectional study based on IT-integrated pop-up questionnaires addressing patients' health problems. We included only telephone contacts that were categorized according to their triage outcome as telephone consultations, direct admissions to hospital or referrals for face-to-face contact. The GP-assessed severity was calculated for age groups and types of outcome. We identified the 20 most frequent primary RFEs and diagnoses for each type of contact termination.

RESULTS

We included 7810 telephone calls. Calls considered non-severe made up two-thirds of the calls terminated as telephone consultations, whereas calls considered potentially severe made up the main part of referrals (52.3%). Overall, the 20 most frequent RFEs accounted for 45.2% of all RFEs, fever being the most frequent (10.0%). Some RFEs were terminated mostly as telephone consultations [e.g. insect bite/sting (75.9%)], whereas others were most often referred for a face-to-face contact [i.e. dyspnoea (79.1%)] or directly to hospital [i.e. chest pain (29.4%)].

CONCLUSION

The distribution of the RFEs on triage outcomes, dominated by more severe diagnoses in referrals indicates a suitable referral level. However, future research on factors related to the demanding task of telephone triage is highly relevant for postdoctoral training of GPs.

Swellable Coatings for Hearing Aid Applications

The problem of acoustic feedback in hearing aids could be solved potentially by applying a compliant hydrogel to the outer surface that would conform to the ear canal and block feedback. With this objective, several formulations of hydrogels were developed and their swelling and mechanical properties investigated. Hydrogel formulations were polymerized from hydroxyethyl methacrylate (HEMA) and N-vinyl-pyrrolidone (NVP), with various photo-initiators, crosslinkers, and swelling agents. The hydrogel that swelled most rapidly and yet remained undissolved in water had a monomer composition of 40 mol% HEMA, 60 mol% NVP, with 1 wt% polyethylene glycol dimethacrylate as a crosslinker, and 0.5 wt% 2,2-dimethoxy-2-phenyl-acetophenone as the photo-initiator. The tensile modulus, strength, hardness, and durability of the dry hydrogels were not a strong function of composition. In the swollen state, the mechanical properties were much reduced. The potential use of these materials on hearing aids has been discussed in this article.

Experimental Induction of Muscle Tenderness and Headache in Tension-Type Headache Patients

The aim of the present study was to investigate the impact of static contraction of the shoulder and neck muscles on muscle tenderness and headache in patients with tension-type headache. Twenty patients with frequent episodic tension-type headache and 20 healthy age- and sex-matched controls were examined using a placebo-controlled cross-over design. The subjects performed static contraction of the trapezius muscles (active procedure) or the anterior tibial muscles (placebo procedure) with 10% of maximal force for 30 min. Total tenderness score, local tenderness score and headache intensity were evaluated before and after the static work. Changes in headache intensity were followed for 24 h. Pericranial tenderness increased significantly more in patients than in controls after the active procedure ( P = 0.04). The increase in pericranial tenderness tended to be higher after the active procedure than after the placebo procedure in patients ( P = 0.08) and in controls ( P = 0.07). Sixty per cent of the patients and 20% of the healthy controls developed headache after the active procedure. Fifty per cent of the patients and none of the controls developed headache after the placebo procedure. There was no significant difference in headache development between the active and the placebo procedure in patients or controls. These findings demonstrate that tension-type headache patients are more liable to develop shoulder and neck pain in response to static exercise than healthy controls.

The Danish cancer pathway for patients with serious non-specific symptoms and signs of cancer-a cross-sectional study of patient characteristics and cancer probability

BACKGROUND

A Danish cancer pathway has been implemented for patients with serious non-specific symptoms and signs of cancer (NSSC-CPP). The initiative is one of several to improve the long diagnostic interval and the poor survival of Danish cancer patients. However, little is known about the patients investigated under this pathway. We aim to describe the characteristics of patients referred from general practice to the NSSC-CPP and to estimate the cancer probability and distribution in this population.

METHODS

A cross-sectional study was performed, including all patients referred to the NSSC-CPP at the hospitals in Aarhus or Silkeborg in the Central Denmark Region between March 2012 and March 2013. Data were based on a questionnaire completed by the patient's general practitioner (GP) combined with nationwide registers. Cancer probability was the percentage of new cancers per investigated patient. Associations between patient characteristics and cancer diagnosis were estimated with prevalence rate ratios (PRRs) from a generalised linear model.

RESULTS

The mean age of all 1278 included patients was 65.9 years, and 47.5 % were men. In total, 16.2 % of all patients had a cancer diagnosis after six months; the most common types were lung cancer (17.9 %), colorectal cancer (12.6 %), hematopoietic tissue cancer (10.1 %) and pancreatic cancer (9.2 %). All patients in combination had more than 80 different symptoms and 51 different clinical findings at referral. Most symptoms were non-specific and vague; weight loss and fatigue were present in more than half of all cases. The three most common clinical findings were 'affected general condition' (35.8 %), 'GP's gut feeling' (22.5 %) and 'findings from the abdomen' (13.0 %). A strong association was found between GP-estimated cancer risk at referral and probability of cancer.

CONCLUSIONS

In total, 16.2 % of the patients referred through the NSSC-CPP had cancer. They constituted a heterogeneous group with many different symptoms and clinical findings. The GP's gut feeling was a common reason for referral which proved to be a strong predictor of cancer. The GP's overall estimation of the patient's risk of cancer at referral was associated with the probability of finding cancer.

The 30-day prognosis of chronic-disease patients after contact with the out-of-hours service in primary healthcare

OBJECTIVE

Little is known about the prognosis of patients with chronic disease who contact the out-of-hours (OOH) service in primary care. The characteristics of contacts with the Danish out-of-hours service and daytime general practice, hospitalization, and death were studied during a 30-day follow-up period in patients with chronic heart diseases.

DESIGN

Cohort study.

SETTING AND SUBJECTS

The study was based on data from 11 897 adults aged 18 + years from a Danish survey of OOH contacts, including information on consultation type. Reason for encounter (RFE) was categorized by OOH GPs at triage as either "exacerbation" or "new health problem". Registry data were used to identify eligible patients, and the cohort was followed for 30 days after OOH contact through nationwide registries on healthcare use and mortality.

MAIN OUTCOME MEASURES

The 30-day prognosis of chronic-disease patients after OOH contact.

RESULTS

Included patients with chronic disease had a higher risk of new OOH contact, daytime GP contact, and hospitalization than other patients during the 30-day follow-up period. OOH use was particularly high among patients with severe mental illness. A strong association was seen between chronic disease and risk of dying during follow-up.

CONCLUSION

Patients with chronic disease used both daytime general practice and the out-of-hours service more often than others during the 30-day follow-up period; they were more often hospitalized and had higher risk of dying. The findings call for a proactive approach to future preventive day care and closer follow-up of this group, especially patients with psychiatric disease.

Antibiotic prescribing patterns in out-of-hours primary care: a population-based descriptive study

OBJECTIVE

To describe the frequency and characteristics of antibiotic prescribing for different types of contacts with the Danish out-of-hours (OOH) primary care service.

DESIGN

Population-based observational registry study using routine registry data from the OOH registration system on patient contacts and ATC-coded prescriptions.

SETTING

The OOH primary care service in the Central Denmark Region.

SUBJECTS

All contacts with OOH primary care during a 12-month period (June 2010-May 2011).

MAIN OUTCOME MEASURES

Descriptive analyses of antibiotic prescription proportions stratified for type of antibiotic, patient age and gender, contact type, and weekdays or weekend.

RESULTS

Of the 644 777 contacts registered during the study period, 15.0% received an antibiotic prescription: 26.1% resulted from clinic consultations, 10.7% from telephone consultations, and 10.9% from home visits. The prescription proportion was higher for weekends (17.6%) than for weekdays (10.6%). The most frequently prescribed antibiotic drugs were beta-lactamase sensitive penicillins (34.9%), antibiotic eye drops (21.2%), and broad-spectrum penicillins (21.0%). Most antibiotic eye drops (73%) were prescribed in a telephone consultation. Most antibiotics were prescribed at 4-6 p.m. on weekdays. Young infants received most antibacterial eye drops (41.3%), patients aged 5-17 years and 18-60 years received most beta-lactamase sensitive penicillins (44.6% and 38.9%, respectively), while patients aged 60 + years received most broad-spectrum penicillins (32.9% of all antibiotic prescriptions).

CONCLUSION

Antibiotics were most often prescribed in clinic consultations, but, in absolute terms, many were also prescribed by telephone. The high prescription proportion, particularly antibacterial eye drops for young infants, suggests room for improvement in rational antibiotic use.

Daytime use of general practice and use of the out-of-hours primary care service for patients with chronic disease: a cohort study

Background

The importance of proactive chronic care has become increasingly evident. Yet, it is unknown whether the use of general practice (GP) during daytime may affect the use of Out-of-Hours (OOH) Primary Care Service for people with chronic disease. We aimed to analyse the association between use of daytime general practice (GP) and use of OOH services for heart disease, lung disease, diabetes, psychiatric disease, or cancer. In particular, we intended to study the association between OOH contacts due to chronic disease exacerbation and recent use of daytime GP.

Methods

Data comprised a random sample of contacts to the OOH services (‘LV-KOS2011’). Included patients were categorised into the following chronic diseases: heart disease, lung disease, diabetes, psychiatric disease, or cancer. Information on face-to-face contacts to daytime GP was obtained from the Danish National Health Insurance Service Registry and information about exacerbation or new episodes from the LVKOS2011 survey. Associations between number of regular daytime consultations and annual follow-up consultations during one, three, six, and 12 months prior to index contacts, and outcomes of interest were estimated by using logistic regression.

Results

In total, 11,897 patients aged ≥ 18 years were included. Of these, 2,665 patients (22.4%) were identified with one of the five selected chronic diseases; 673 patients (5.7%) had two or more. A higher odds ratio (OR) for exacerbation as reason for encounter (RFE) at the index contact was observed among patients with psychiatric disease (OR = 2.15) and cancer (OR = 2.17) than among other patients for ≥2 daytime recent contacts. When receiving an annual follow-up, exacerbation OR at index contact lowered for patients with lung disease (OR = 0.68), psychiatric disease (OR = 0.42), or ≥2 diseases (OR = 0.61).

Conclusion

Recent and frequent use of daytime GP for patients with the selected chronic diseases was associated with contacts to the OOH services due to exacerbation. These findings indicate that the most severely chronically ill patients tend to make more use of general practice. The provision of an annual follow-up daytime GP consultation may indicate a lower risk of contacting OOH due to exacerbation.

Drug prescription by telephone consultation in Danish out-of-hours primary care: a population-based study of frequency and associations with clinical severity and diagnosis

Background

Danish general practitioners (GPs) answer all calls to the out-of-hours primary care service. About 60% of the calls are terminated on the telephone through provision of medical advice and prescription of medication. Nevertheless, little is known about the prescription patterns of telephone consultations, such as prescription frequency and indications for drug use. Our aim was to examine the characteristics of patients and GPs in telephone consultations resulting in drug prescription.

Methods

The study was based on a 12-month survey on reasons for encounter in the Danish out-of-hours primary care service. A total of 385 GPs (55.5% of all GPs from Central Denmark Region on duty during a year) participated in answering electronic pop-up questionnaires integrated in the electronic patient administration system. The questionnaires contained items on reasons for encounter (e.g. existing chronic disease or new health problem), diagnoses, and GP-assessed severity of the health problem. Data on time of contact, patient gender and age, and prescribed medication (Anatomic Therapeutic Chemical classifications) for telephone consultations were obtained from the patient administration system. Differences in characteristics of patients, general practitioners, and contacts were examined, and associations with prescribed medication were analysed using a multivariate analysis with prevalence ratios.

Results

Medication was prescribed in 19.9% of the included 4,173 telephone consultations; antibiotics and analgesics were prescribed most frequently (10.8% and 2.5%, respectively). GPs tended to assess contacts resulting in antibiotic prescription as more severe than other contacts. For high-severity contacts, there was a lower likelihood for prescription (prevalence ratio = 0.28 (0.16-0.47)). Children aged 0-4 years had lower probability of receiving a prescription compared with patients aged 18-40 years. The prescription rate was highest during the first four hours of the opening hours of the out-of-hours primary care service.

Conclusion

One in five of all telephone consultations involved drug prescription; antibiotics constituted half of these prescriptions. Drug prescription by telephone was less likely to be offered in cases involving ‘severe’ reason for encounter or children. This study calls for further studies of drug prescriptions issued via out-of-hours primary care telephone consultations.

Chronic-disease patients and their use of out-of-hours primary health care: a cross-sectional study

Background

The general practitioner (GP) plays an important role for chronic disease care. Continuous and close contact with daytime general practice is intended to prevent medical problems arising outside office hours due to already diagnosed chronic disease. However, previous studies indicate that patients with chronic diseases are frequent users of out-of-hours primary care services (OOH), but knowledge is limited on reasons for encounter (RFE), severity of symptoms, and OOH patient handling. We aimed to describe contacts to the OOH services from patients with chronic heart disease, lung disease, severe psychiatric disorders, diabetes, and cancer in terms of RFE, OOH GP diagnosis, assessed severity of symptoms, and actions taken by the GP.

Methods

Eligible patients (aged 18 years and older) were randomly sampled from a one-year cross-sectional study comprising 15,229 contacts to the OOH services in the Central Denmark Region. A cohort of patients with one or more of the five selected chronic diseases were identified by linking data on the Danish civil registration number (CPR) through specific nationwide Danish health registers.

Results

Out of 13,930 identified unique patients, 4,912 had at least one of the five chronic diseases. In total, 25.9% of all calls to the OOH services came from this chronic disease patient group due to an acute exacerbation; 32.6% of these calls came from patients with psychiatric diagnoses. Patients with chronic disease were more likely to receive a face-to-face contact than the remaining group of patients, except for calls from patients with a psychiatric disorder who were more often completed through a telephone consultation. Patients with heart disease calling due to a new health problem formed the largest proportion of all OOH referrals to hospital (13.3%) compared to calls from the other groups with chronic disease (3.4-6.7%).

Conclusions

A third of the patients randomly sampled by their OOH call had one or more of the five selected chronic diseases (i.e. chronic lung disease, heart disease, diabetes, psychiatric disease, or cancer). Patients with chronic disease were more often managed by OOH GPs than other patients.

A feasible method to study the Danish out-of-hours primary care service

INTRODUCTION

The primary care out-of-hours (OOH) service is of considerable importance; it is the main provider of freely accessible medical advice outside daytime hours, and it covers 75% of the active time in the health-care system. Although the OOH handles three million contacts annually, only little is known about the reasons for encounter, the performed clinical work and the patient perspectives.

MATERIAL AND METHODS

During a one-year period (2010-2011), data on patient contacts were collected using pop-up questionnaires integrated into the existing IT system. The questions explored the contents and characteristics of patient contacts. A paper-based questionnaire was sent to the included patients.

RESULTS

Of all 700 general practitioners (GP) on duty, 383 (54.7%) participated at least once, and the participating GPs were representative of all GPs. In total, 21,457 contacts were registered; and the distribution of patient, contact and GP characteristics in OOH contacts was similar to the background contacts. Telephone consultations were most often offered to children and home visits primarily to elderly patients. The patient response rate was 51.2%. Females comprised the majority of the included contacts and of the respondents in the patient survey.

CONCLUSION

The method was highly feasible for generating a representative sample of contacts to OOH services. The project has formed a substantial and valid basis for further studies and future research in the OOH service.

FUNDING

Financed by the Region of Central Jutland, the Danish National Research Foundation for Primary Care and the Health Foundation.

TRIAL REGISTRATION

not relevant.

Consumption in out-of-hours health care: Danes double Dutch?

OBJECTIVE

To study the quantitative consumption in out-of-hours (OOH) primary care in Denmark and the Netherlands, in the context of OOH care services.

DESIGN

A retrospective observational study describing contacts with OOH care services, using registration data.

SETTING

OOH care services (i.e. OOH primary care, emergency department, and ambulance care) in one Danish and one Dutch region.

SUBJECTS

All patients contacting the OOH care services in September and October 2011.

MAIN OUTCOME MEASURES

Consumption as number of contacts per 1000 inhabitants in total and per age group per contact type.

RESULTS

For the two-month period the Danes had 80/1000 contacts with OOH primary care compared with 50/1000 for the Dutch. The number of contacts per 1000 inhabitants per age group varied between the regions, with the largest difference in the 0-5 years age group and a considerable difference in the young-adult groups (20-35 years). The difference was largest for telephone consultations (47/1000 vs. 20/1000), particularly in the youngest age group (154/1000 vs. 39/1000). The Danes also had more home visits than the Dutch (10/1000 vs. 5/1000), while the Dutch had slightly more clinic consultations per 1000 inhabitants than the Danes (25/1000 vs. 23/1000).

CONCLUSION

The Danish population has more contacts with OOH primary care, particularly telephone consultations, especially concerning young patients. Future research should focus on the relevance of contacts and identification of factors related to consumption in OOH primary care.

Longing for existential recognition: a qualitative study of everyday concerns for people with somatoform disorders

OBJECTIVE

Patients with somatoform disorders could be vulnerable to stressors and have difficulties coping with stress. The aim was to explore what the patients experience as stressful and how they resolve stress in everyday life.

METHODS

A cross-sectional retrospective design using 24 semi-structured individual life history interviews. Data-analysis was based on grounded theory.

RESULTS

A major concern in patients was a longing for existential recognition. This influenced the patients' self-confidence, stress appraisals, symptom perceptions, and coping attitudes. Generally, patients had difficulties with self-confidence and self-recognition of bodily sensations, feelings, vulnerability, and needs, which negatively framed their attempts to obtain recognition in social interactions. Experiences of recognition appeared in three different modalities: 1) "existential misrecognition" covered the experience of being met with distrust and disrespect, 2) "uncertain existential recognition" covered experiences of unclear communication and a perception of not being totally recognized, and 3) "successful existential recognition" covered experiences of total respect and understanding. "Misrecognition" and "uncertain recognition" related to decreased self-confidence, avoidant coping behaviours, increased stress, and symptom appraisal; whereas "successful recognition" related to higher self-confidence, active coping behaviours, decreased stress, and symptom appraisal.

CONCLUSION

Different modalities of existential recognition influenced self-identity and social identity affecting patients' daily stress and symptom appraisals, self-confidence, self-recognition, and coping attitudes. Clinically it seems crucial to improve the patients' ability to communicate concerns, feelings, and needs in social interactions. Better communicative skills and more active coping could reduce the harm the patients experienced by not being recognized and increase the healing potential of successful recognition.

Guidelines adherence to lower urinary tract infection treatment in out-of-hours primary care in European countries

BACKGROUND

The substantial prevalence of bacterial lower urinary tract infections (LUTIs) in out-of-hours (OOH) primary care is a reason for frequent prescription of antibiotics. Insight in guideline adherence in OOH primary care concerning treatment of LUTIs is lacking.

AIMS

To check feasibility of the use of OOH routine data to assess guideline adherence for the treatment of LUTI in OOH primary care, in different regions of Europe.

METHODS

We compared guidelines for diagnosis and treatment of uncomplicated LUTIs in nine European countries, followed by an observational study on available data of guideline adherence. In each region a convenience sample of registration data of at least 100 contacts per OOH primary care setting was collected. Data on adherence (% of contacts) was identified for type of antibiotic and for full treatment adherence (i.e. recommended type and dose and duration).

RESULTS

Six countries were able to provide data on treatment of LUTIs. Four of them succeeded to collect data on type, dosage and duration of treatment. Mostly, trimethoprim was the treatment of first choice, sometimes combined with sulfamethoxazol or sulfamethizol. Adherence with the type of antibiotics varied from 25% to 100%. Denmark achieved a full treatment adherence of 40.0%, the Netherlands 72.7%, Norway 38.3%, and Slovenia 22.2%.

CONCLUSION

Guidelines content is similar to a large extent in the participating countries. The use of OOH routine data for analysis of guideline adherence in OOH primary care seems feasible, although some challenges remain. Adherence regarding treatment varies and suggests room for improvement in most countries.

EurOOHnet-the European research network for out-of-hours primary health care

BACKGROUND AND RATIONALE

European countries face similar challenges in the provision of health care. Demographic factors like ageing, population growth, changing patient behaviour, and lack of work force lead to increasing demands, costs, and overcrowding of out-of-hours (OOH) care (i.e. primary care services, emergency departments (EDs), and ambulance services). These developments strain services and imply safety risks. In the last few decades, countries have been re-organizing their OOH primary health care services. AIM AND SCOPE OF THE NETWORK: We established a European research network for out-of-hours primary health care (EurOOHnet), which aims to transfer knowledge, share experiences, and conduct research. Combining research competencies and integrating results can generate a profound information flow to European researchers and decision makers in health policy, contributing towards feasible and high-quality OOH care. It also contributes to a more comparable performance level within European regions. CONDUCTED RESEARCH PROJECTS: The European research network aims to conduct mutual research projects. At present, three projects have been accomplished, among others concerning the diagnostic scope in OOH primary care services and guideline adherence for diagnosis and treatment of cystitis in OOH primary care.

THE FUTURE

Future areas of research will be organizational models for OOH care; appropriate use of the OOH services; quality of telephone triage; quality of medical care; patient safety issues; use of auxiliary personnel; collaboration with EDs and ambulance care; and the role of GPs in OOH care.