1
|
Christensen LD, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB, Huibers L. Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark. BMC Prim Care 2024; 25:31. [PMID: 38262975 PMCID: PMC10804570 DOI: 10.1186/s12875-024-02264-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Ellen Keizer
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| |
Collapse
|
2
|
Nystøyl DS, Østerås Ø, Hunskaar S, Zakariassen E. Acute medical missions by helicopter medical service (HEMS) to municipalities with different approach for primary care physicians. BMC Emerg Med 2022; 22:102. [PMID: 35676626 PMCID: PMC9178819 DOI: 10.1186/s12873-022-00655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 05/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background The prehospital emergency system in Norway involves out-of-hours (OOH) services with on-call physicians. Helicopter emergency medical service (HEMS) are used in cases of severe illness or trauma that require rapid transport and/or an anesthesiologist’s services. In recent years, on-call primary care physicians have been less available for call-outs in Norway, and HEMS may be requested for missions that could be adequately handled by on-call physicians. Here, we investigated how different availability of an on-call physician to attend emergency patients at site (call-out) impacted requests and use of HEMS. Methods Our analysis included all acute medical missions in an urban and nearby rural OOH district, which had different approach regarding physician call-outs from the OOH service. For this prospective observational study, we used data from both HEMS and the OOH service from November 1st 2017 until November 30th 2018. Standard descriptive statistical analyses were used. Results The rates of acute medical missions in the urban and rural OOH districts were similar (30 and 29 per 1000 inhabitants per year, respectively). The rate of HEMS requests was significantly higher in the rural OOH district than in the urban district (2.4 vs. 1.7 per 1000 inhabitants per year, respectively). Cardiac arrest and trauma were the major symptom categories in more than one half of the HEMS-attended patients, in both districts. Chest pain was the most frequent reason for an OOH call-out in the rural OOH district (21.1%). An estimated NACA score of 5–7 was found in 47.7% of HEMS patients from the urban district, in 40.0% of HEMS patients from the rural OOH district (p = 0.44), and 12.8% of patients attended by an on-call physician in the rural OOH district (p < 0.001). Advanced interventions were provided by an anesthesiologist to one-third of the patients attended by HEMS, of whom a majority had an NACA score of ≥ 5. Conclusions HEMS use did not differ between the two compared areas, but the rate of HEMS requests was significantly higher in the rural OOH district. The threshold for HEMS use seems to be independent of on-call primary care physician involvement.
Collapse
Affiliation(s)
- Dag Ståle Nystøyl
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway. .,Department of Global Public Health and Primary Care, Group for Health Services Research, University of Bergen, Bergen, Norway.
| | - Øyvind Østerås
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, Group for Health Services Research, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Erik Zakariassen
- Department of Global Public Health and Primary Care, Group for Health Services Research, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| |
Collapse
|
3
|
Huibers L, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB. Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study. Scand J Prim Health Care 2022; 40:227-236. [PMID: 35703579 PMCID: PMC9397449 DOI: 10.1080/02813432.2022.2073981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Linda Huibers
- Research Unit for General Practice, Aarhus, Denmark
- CONTACT Linda Huibers Research Unit for General Practice, Bartholins Alle 2, Aarhus8000, Denmark
| | | | - Ellen Keizer
- Research Unit for General Practice, Aarhus, Denmark
| | - Bodil Hammer Bech
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
| |
Collapse
|
4
|
Blinkenberg J, Hetlevik Ø, Sandvik H, Baste V, Hunskaar S. Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study. BMC Health Serv Res 2022; 22:78. [PMID: 35033069 PMCID: PMC8761320 DOI: 10.1186/s12913-021-07444-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral. Methods A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR. Results Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men. Conclusions The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.
Collapse
Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009, Bergen, Norway.
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009, Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009, Bergen, Norway
| |
Collapse
|
5
|
Nystøyl DS, Røislien J, Østerås Ø, Hunskaar S, Breidablik HJ, Zakariassen E. Helicopter emergency medical service (HEMS) activity after increased distance to out-of-hours services: an observational study from Norway. BMC Emerg Med 2020; 20:88. [PMID: 33138780 PMCID: PMC7607704 DOI: 10.1186/s12873-020-00377-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background Organizational changes in out-of-hour (OOH) services may have unintended consequences for other prehospital services. Reports indicate an increased use of helicopter emergency medical services (HEMS) after changes in OOH services in Norway due to greater geographical distances for the on-call doctors. We investigated whether HEMS dispatches increased when nine municipalities in Sogn og Fjordane County merged into one large inter-municipal OOH district. Methods All primary dispatches of the HEMS in the county between 2004 and 2013 were included. We applied interrupted time series regression to monthly aggregated data to evaluate the impact of the organizational change 1 April 2009. The nine target municipalities were compared to the rest of the municipalities in the county, which served as a control group. A quasipoisson model adjusted for seasonality was found to be most applicable. Results We included 8,751 dispatches, 5,009 (57.2%) of which were completed with a patient encounter. Overall, we found no alteration in requests for HEMS after 2009 (p = 0.251). Separate analyses of the target municipalities and control group revealed no significant increase after 2009 (p = 0.400 and p = 0.056, respectively). When categorizing the municipalities into urban or rural, we found a general increase in HEMS dispatches for the rural group over the 10-year span (p = 0.045) but no added increase after 2009 (p = 0.502). The urban subgroup showed no change. Distance from the OOH service in regards to travel increased within the nine municipalities after 2009, median [quartiles] (5.0[3.0, 6.2] km vs 26.5[5.0, 62.2] km, p < 0.001). Conclusion After relocating nine local OOH services into one large inter-municipal OOH district, we found no increase in requests for HEMS.
Collapse
Affiliation(s)
- Dag Ståle Nystøyl
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway. .,Health Services Research Group, Department of Global Public Health and Primary Care, University of Bergen, PBox 7810, 5020, Bergen, Norway.
| | - Jo Røislien
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Øyvind Østerås
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Steinar Hunskaar
- Health Services Research Group, Department of Global Public Health and Primary Care, University of Bergen, PBox 7810, 5020, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | | | - Erik Zakariassen
- Health Services Research Group, Department of Global Public Health and Primary Care, University of Bergen, PBox 7810, 5020, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| |
Collapse
|
6
|
Rebnord IK, Morken T, Maartmann-Moe K, Hunskaar S. Out-of-hours workload among Norwegian general practitioners - an observational study. BMC Health Serv Res 2020; 20:944. [PMID: 33054822 PMCID: PMC7557051 DOI: 10.1186/s12913-020-05773-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 09/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Repeated studies of working hours among Norwegian regular general practitioners (RGPs) have shown that the average total number of weekly working hours has remained unchanged since 1994 and up until 2014. For both male and female RGPs, the mean total weekly working hours amounted to almost 50 h in 2014. In recent years, Norwegian RGPs have become increasingly dissatisfied. They experience significantly increased workload without compensation in the form of more doctors or better payment. A study from the Norwegian Directorate of Health in 2018 (the RGP study) showed that Norwegian RGPs worked 55.6 h weekly (median 52.5). 25% of the respondents worked more than 62.2 h weekly. Based on data from the RGP study we investigated Norwegian RGP’s out-of-hours (OOH) work, how the working time was distributed, and to what extent the OOH work affected the regular working hours. Methods In early 2018, an electronic survey was sent to all 4640 RGPs in Norway. Each RGP reported how many minutes that were spent that particular day on various tasks during seven consecutive days. Working time also included additional tasks in the municipality, other professional medical work and OOH primary health care. Differences were analysed by independent t-tests, and regression analyses. Results One thousand eighty hundred seventy-six RGPs (40.4%) responded, 640 (34.1%) had registered OOH work. Male RGPs worked on average 1.5 h more doing regular work than did females (p = 0.001) and on average 2.3 h more OOH work than females (p = 0.079). RGPs with no OOH work registered a mean of 1.0 h more clinical work than RGPs working OOH (p = 0.043). There was a large variation in OOH working hours. A linear regression analysis showed that male RGPs and RGPs in rural areas had the heaviest OOH workload. Conclusions One in three Norwegian RGPs undertook OOH work during the registration week in the RGP study. OOH work was done in addition to a sizeable regular workload as an RGP. We found small gender differences. OOH work was not compensated with reduced regular RGP work.
Collapse
Affiliation(s)
- Ingrid Keilegavlen Rebnord
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Aarstadveien 17, NO-5009, Bergen, Norway.
| | - Tone Morken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Aarstadveien 17, NO-5009, Bergen, Norway
| | | | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Aarstadveien 17, NO-5009, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| |
Collapse
|
7
|
Søvsø MB, Huibers L, Bech BH, Christensen HC, Christensen MB, Christensen EF. Acute care pathways for patients calling the out-of-hours services. BMC Health Serv Res 2020; 20:146. [PMID: 32106846 PMCID: PMC7045402 DOI: 10.1186/s12913-020-4994-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Morten Breinholt Søvsø
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
| | | | | | - Erika Frischknecht Christensen
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| |
Collapse
|
8
|
Søvsø MB, Christensen MB, Bech BH, Christensen HC, Christensen EF, Huibers L. Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes. BMC Health Serv Res 2019; 19:813. [PMID: 31699103 PMCID: PMC6839230 DOI: 10.1186/s12913-019-4674-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/24/2019] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | | | - Bodil Hammer Bech
- Department of Public Health, Research Unit of Epidemiology, Aarhus University, Aarhus, Denmark
| | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| |
Collapse
|
9
|
Blinkenberg J, Pahlavanyali S, Hetlevik Ø, Sandvik H, Hunskaar S. General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study. BMC Health Serv Res 2019; 19:568. [PMID: 31412931 PMCID: PMC6693245 DOI: 10.1186/s12913-019-4419-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/09/2019] [Indexed: 12/11/2022] Open
Abstract
Background Primary care doctors have a gatekeeper function in many healthcare systems, and strategies to reduce emergency hospital admissions often focus on general practitioners’ (GPs’) and out-of-hours (OOH) doctors’ role. The aim of the present study was to investigate these doctors’ role in emergency admissions to somatic hospitals in the Norwegian public healthcare system, where GPs and OOH doctors have a distinct gatekeeper function. Methods A cross-sectional analysis was performed by linking data from the Norwegian Patient Registry (NPR) and the physicians’ claims database. The referring doctor was defined as the physician who had sent a claim for a consultation with the patient within 24 h prior to an emergency admission. If there was no claim registered prior to hospital arrival, the admission was defined as direct, representing admissions from ambulance services, referrals from nursing home doctors, and admissions initiated by in-hospital doctors. Results In 2014 there were 497,587 emergency admissions to somatic hospitals in Norway after excluding birth related conditions. Direct admissions were most frequent (43%), 31% were referred by OOH doctors, 25% were referred by GPs, whereas only 2% were referred from outpatient clinics or private specialists with public contract. Direct admissions were more common in central areas (52%), here GPs’ referrals constituted only 16%. The prehospital paths varied with the hospital discharge diagnosis. For anaemias, 46–49% were referred by GPs, for acute appendicitis and mental/alcohol related disorders 52 and 49% were referred by OOH doctors, respectively. For both malignant neoplasms and cardiac arrest 63% were direct admissions. Conclusions GPs or OOH doctors referred many emergencies to somatic hospitals, and for some clinical conditions GPs’ and OOH doctors’ gatekeeping role was substantial. However, a significant proportion of the emergency admissions was direct, and this reduces the impact of the GPs’ and OOH doctors’ gatekeeper roles, even in a strict gatekeeping system.
Collapse
Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway.
| | - Sahar Pahlavanyali
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| |
Collapse
|
10
|
Sandvik H, Hunskaar S. Frequent attenders at primary care out-of-hours services: a registry-based observational study in Norway. BMC Health Serv Res 2018; 18:492. [PMID: 29940934 PMCID: PMC6020190 DOI: 10.1186/s12913-018-3310-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/19/2018] [Indexed: 11/27/2022] Open
Abstract
Background Out-of-hours (OOH) services are often consulted for problems that are non-urgent. Some of these patients are frequent attenders (FAs) who may constitute a heavy burden on the OOH service. The aim of the present study was to analyse FAs in a comprehensive material, covering all patients who have visited OOH services in Norway during a 10-year period. Methods FA was defined as a patient having ≥5 consultations during one year. A cohort of all 15,172 FAs in 2008 was followed until 2017, with a description of demographics, consultations, and diagnoses for each year. FAs in 2017 were also analysed with more extreme definitions (≥10, ≥20, ≥30 consultations). To analyse predictors for FA a logistic regression analysis was performed on the 2017 data. Results FAs constituted 2% of all patients (U-shaped age curve and female overrepresentation) and approximately 10% of all consultations each year. 59.8% of the cohort was never FA again, 17.7% had one relapse, 8.6% two, and 4.4% had three relapses. 22.8% was also a FA in 2009. Thereafter the percentage gradually declined to 6.2% in 2017. Only 0.8% of the original cohort were persistent FAs throughout the 10-year period. FAs were three times as likely to be given a psychological diagnosis as the average OOH patient, and this percentage increased in persistent and more extreme FAs. FAs tended to seek help at inconvenient hours (late evening and night), and increasingly so the more extreme they were. Also, they needed more consultation time and more often received home visits. The logistic regression analysis identified the following predictors for becoming FA (odds ratio = OR): Female (OR 1.17), age 0–1 years (OR 3.46), age 70+ (OR 1.57), small municipality (OR 1.61), psychological diagnosis (OR 10.00), social diagnosis (OR 5.97), cancer (OR 6.76), diabetes (OR 4.65), and chronic obstructive pulmonary disease (OR 7.81). Conclusions FAs were most common among the youngest children and among the elderly, increasing with age. Females were overrepresented, as were patients with psychosocial problems and various chronic somatic conditions. The majority were only temporary FAs.
Collapse
Affiliation(s)
- Hogne Sandvik
- National Centre for Emergency Primary Health Care, Uni Research Health, Kalfarveien 31, 5018, Bergen, Norway.
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, Uni Research Health, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| |
Collapse
|
11
|
Gamst-Jensen H, Lippert FK, Egerod I. Under-triage in telephone consultation is related to non-normative symptom description and interpersonal communication: a mixed methods study. Scand J Trauma Resusc Emerg Med 2017; 25:52. [PMID: 28506282 PMCID: PMC5433057 DOI: 10.1186/s13049-017-0390-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background Telephone consultation and triage are used to limit the workload on emergency departments. Lack of visual cues and clinical tests put telephone consultations to a disadvantage compared to face-to-face consultations increasing the risk of under-triage. Under-triage occurs in telephone triage; however why under-triage happens is not explored yet. The aim of the study was to describe situations of under-triage in context, to assess the quality of under-triaged calls, and to identify communication patterns contributing to under-triage in a regional OOH service in the capital region of Denmark. Methods Explanatory simultaneous mixed method with thematic analysis and descriptive statistics was chosen. The study was carried out in an Out-Of-Hours service (OOH) in the Capital Region of Denmark, Copenhagen. Under-triage was defined as Potentially Under-Triaged Calls (PUTC) by specific criteria to an OOH Hotline, and identification by integration of three databases: Medical Hotline database, Emergency number database, including the Ambulance database, and electronic patient records. Distribution of PUTC were carried out using ICD-10 codes to identify diagnosis and main themes identified by qualitative analysis of audio recorded under-triaged calls. Study period was October 15th to November 30th 2014. Results Three hundred twenty seven PUTC were identified, representing 0.04% of all calls (n = 937.056) to the OOH. Distribution of PUTC according to diagnoses was: digestive (24%), circulatory (19%), respiratory (15%) and all others (42%). Thematic analysis of the voice logs suggested that inadequate communication and non-normative symptom description contributed to under-triage. Discussion The incidence of potentially under-triage is low (0.04%). However, the over-representation of digestive, circulatory, and respiratory diagnoses might suggest that under-triage is related to inadequate symptom description. We recommend that caller and call-handler collaborate systematically on problem identification and negotiate non-normative symptom description. Conclusion The incidence of under-triage is low (0.04%). However, the over-representation of digestive, circulatory, and respiratory diagnoses might suggest that under-triage is related to inadequate symptom description. We recommend that caller and call-handler collaborate systematically on problem identification and negotiate non-normative symptom description.
Collapse
Affiliation(s)
- Hejdi Gamst-Jensen
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2. Sal, 2750, Ballerup, Denmark.
| | - Freddy K Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2. Sal, 2750, Ballerup, Denmark
| | - Ingrid Egerod
- Trauma Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
| |
Collapse
|