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Sutherland M, Ehrlich H, McKenney M, Elkbuli A. Trauma outcomes for blunt and penetrating injuries by mode of transportation and day/night shift. Am J Emerg Med 2021; 48:79-82. [PMID: 33862389 DOI: 10.1016/j.ajem.2021.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Effective management of trauma patients is dependent on pre-hospital triage systems and proper in-hospital treatment regardless of time of admission. We aim to investigate any differences in adjusted all-cause mortality between day vs. night arrival for adult trauma patients who were transported to the hospital via ground emergency medical services (GEMS) and helicopter emergency medical services (HEMS) and to determine if care/outcomes are inferior when admitted during the night shift as compared to the day shift. METHODS Retrospective cohort analysis of adult blunt and penetrating injury patients requiring full team trauma activation at an American College of Surgeons Committee on Trauma (ACSCOT)-verified Level 1 trauma center from 2011 to 2019. Descriptive statistical analyses, chi-square analyses, independent-sample t-tests, and Fisher's exact tests were performed. Primary measurement outcome was adjusted observed/expected (O/E) mortality ratios utilizing TRISS methodology. RESULTS 8370 patients with blunt injuries and 1216 patients with penetrating injuries were analyzed. There were no significant differences in day vs. night O/Es overall (blunt 0.65 vs. 0.59; p = 0.46) (penetrating 0.88 vs. 0.87; p = 0.97). There also were no significant differences when stratified by GEMS (blunt 0.64 vs. 0.55; p = 0.08) (penetrating 0.88 vs. 1.10; p = 0.09) and HEMS admissions (blunt 0.76 vs. 0.75; p = 0.91) (penetrating 0.88 vs. 0.91; p = 0.85). CONCLUSIONS At an ACSCOT-verified Level 1 Trauma Center, care/outcomes of patients admitted during the night shift were not inferior to those admitted during the day shift. Trauma Center verification by the ACSCOT and multidisciplinary collaboration may allow for consistent care despite injury type and time of day.
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Affiliation(s)
- Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Haley Ehrlich
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
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2
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Dunbar-Yaffe R, Wu RC, Oza A, Lee-Kim V, Cram P. Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study. CMAJ Open 2021; 9:E667-E672. [PMID: 34145049 PMCID: PMC8248558 DOI: 10.9778/cmajo.20200167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.
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Affiliation(s)
- Richard Dunbar-Yaffe
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont.
| | - Robert C Wu
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Amit Oza
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Victoria Lee-Kim
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Peter Cram
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
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Bell SG, Smith R, Inman ER. It Is Time to Have More After-Hours Gynecological Care for Medical Trainees. Acad Med 2021; 96:16-17. [PMID: 33394658 DOI: 10.1097/acm.0000000000003795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Sarah G Bell
- Fourth-year resident physician, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan;
| | - Roger Smith
- Fourth-year resident physician, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan;
| | - Erin R Inman
- Fourth-year resident physician, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan;
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Why out-of-hours services may not be such good news for owners. Vet Rec 2020; 187:502. [PMID: 33335001 DOI: 10.1136/vr.m4890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This month, a dog owner describes what she experienced when her local practice started using an out-of-hours provider.
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Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study. PLoS One 2020; 15:e0237629. [PMID: 32790804 PMCID: PMC7425859 DOI: 10.1371/journal.pone.0237629] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/30/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND During the COVID-19 pandemic, general practitioners worldwide re-organise care in very different ways because of the lack of evidence-based protocols. OBJECTIVE This paper describes the organisation and the characteristics of consultations in Belgian out-of-hours primary care during five weekends at the peak of a COVID-19 outbreak and compares it to a similar period in 2019. METHODS Real-time observational study using pseudonymised routine clinical data extracted out of reports from home visits, telephone- and physical consultations (iCAREdata). Nine general practice cooperatives (GPCs) participated covering a population of 1 513 523. RESULTS All GPCs rapidly re-organised care in order to handle the outbreak and provide a safe working environment. The average consultation rate was 222 per 100 000 citizens per weekend. These consultations were handled by telephone alone in 40% (N = 6293). A diagnosis at risk of COVID-19 was registered in 6692 (43%) consultations,. Out of 5311 physical consultations, 1460 were at risk of COVID-19 of which 443 (30%) did not receive prior telephone consultation to estimate this risk. Compared to 2019, the workload initially increased due to telephone consultations but afterwards declined drastically. The physical consultation rate declined by 45% with a marked decline in diagnoses unrelated to COVID-19. CONCLUSIONS General practitioners can rapidly re-organise out-of-hours care to handle patient flows during a COVID-19 outbreak. Forty percent of the out-of-hours primary care contacts are handled by telephone consultations alone. We recommend to give a telephone consultation to all patients and not to rely on call takers to differentiate between infectious and regular care. The demand for physical consultations declined drastically provoking questions about patient's safety for care unrelated to COVID-19.
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Affiliation(s)
- Stefan Morreel
- Department of ELIZA (Primary and Interdisciplinary Care), University of Antwerp, Antwerpen, Belgium
| | - Hilde Philips
- Department of ELIZA (Primary and Interdisciplinary Care), University of Antwerp, Antwerpen, Belgium
| | - Veronique Verhoeven
- Department of ELIZA (Primary and Interdisciplinary Care), University of Antwerp, Antwerpen, Belgium
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Foster H, Moffat KR, Burns N, Gannon M, Macdonald S, O'Donnell CA. What do we know about demand, use and outcomes in primary care out-of-hours services? A systematic scoping review of international literature. BMJ Open 2020; 10:e033481. [PMID: 31959608 PMCID: PMC7045150 DOI: 10.1136/bmjopen-2019-033481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To synthesise international evidence for demand, use and outcomes of primary care out-of-hours health services (OOHS). DESIGN Systematic scoping review. DATA SOURCES CINAHL; Medline; PsyARTICLES; PsycINFO; SocINDEX; and Embase from 1995 to 2019. STUDY SELECTION English language studies in UK or similar international settings, focused on services in or directly impacting primary care. RESULTS 105 studies included: 54% from mainland Europe/Republic of Ireland; 37% from UK. Most focused on general practitioner-led out-of-hours cooperatives. Evidence for increasing patient demand over time was weak due to data heterogeneity, infrequent reporting of population denominators and little adjustment for population sociodemographics. There was consistent evidence of higher OOHS use in the evening compared with overnight, at weekends and by certain groups (children aged <5, adults aged >65, women, those from socioeconomically deprived areas, with chronic diseases or mental health problems). Contact with OOHS was driven by problems perceived as urgent by patients. Respiratory, musculoskeletal, skin and abdominal symptoms were the most common reasons for contact in adults; fever and gastrointestinal symptoms were the most common in the under-5s. Frequent users of daytime services were also frequent OOHS users; difficulty accessing daytime services was also associated with OOHS use. There is some evidence to suggest that OOHS colocated in emergency departments (ED) can reduce demand in EDs. CONCLUSIONS Policy changes have impacted on OOHS over the past two decades. While there are generalisable lessons, a lack of comparable data makes it difficult to judge how demand has changed over time. Agreement on collection of OOHS data would allow robust comparisons within and across countries and across new models of care. Future developments in OOHS should also pay more attention to the relationship with daytime primary care and other services. PROSPERO REGISTRATION NUMBER CRD42015029741.
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Affiliation(s)
- Hamish Foster
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Keith R Moffat
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Nicola Burns
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Maria Gannon
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Sara Macdonald
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
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Martindale S, Golightly D, Pinchin J, Shaw D, Blakey J, Perez I, Sharples S. An interview analysis of coordination behaviours in Out-of-Hours secondary care. Appl Ergon 2019; 81:102861. [PMID: 31422271 DOI: 10.1016/j.apergo.2019.05.011] [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] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 03/19/2019] [Accepted: 05/22/2019] [Indexed: 06/10/2023]
Abstract
This paper seeks to elicit and structure the factors that shape the execution and, in particular, the coordination of work in Out of Hours care. Evenings and weekends in UK hospitals are managed by specific Out of Hours (OoH) care arrangements, and associated technology. Managing care within the constraints of staff availability and demands is a key concern for both patient care and staff wellbeing, yet has received little attention from healthcare human factors. A study of sixteen clinical staff used Critical Decision Method to understand how work is coordinated and the constraints and criteria that are applied by the roles managing OoH care. The analysis identified ten types of coordination decision that, in turn, underpinned three types of adaptive behaviour - pre-emption, information augmentation and self-organisation - that were crucial for the effective performance in OoH care. These behaviours explain how OoH staff manage the task demands placed on them, individually and as a team.
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Affiliation(s)
- Sarah Martindale
- Human Factors Research Group/Horizon Digital Economy Research, University of Nottingham, Nottingham, United Kingdom.
| | - David Golightly
- Faculty of Engineering, University of Nottingham, Nottingham, United Kingdom.
| | - James Pinchin
- Human Factors Research Group/Horizon Digital Economy Research, University of Nottingham, Nottingham, United Kingdom; Faculty of Engineering, University of Nottingham, Nottingham, United Kingdom
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, United Kingdom
| | - John Blakey
- Sir Charles Gairdner Hospital, Perth, Australia; Curtin University Medical School, Perth, Australia
| | - Iker Perez
- Human Factors Research Group/Horizon Digital Economy Research, University of Nottingham, Nottingham, United Kingdom
| | - Sarah Sharples
- Faculty of Engineering, University of Nottingham, Nottingham, United Kingdom
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Zinger ND, Blomberg SN, Lippert F, Collatz Christensen H. Satisfaction of 30 402 callers to a medical helpline of the Emergency Medical Services Copenhagen: a retrospective cohort study. BMJ Open 2019; 9:e029801. [PMID: 31597649 PMCID: PMC6797474 DOI: 10.1136/bmjopen-2019-029801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 11/04/2022] Open
Abstract
OBJECTIVES To keep healthcare systems sustainable for future demands, many countries are developing a centralised telephone line for out-of-hours primary care services. To increase the quality of such services, more information is needed on factors that influence caller satisfaction. The aim of this study was to identify demographic and call-related characteristics that are associated with the patient satisfaction of callers to a medical helpline in Denmark. DESIGN Retrospective cohort study on patient registry data and questionnaire results. SETTING Non-emergency medical helpline in the Capital Region of Denmark. PARTICIPANTS A random sample of 30 402 callers to the medical helpline between May 2016 and May 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Responses of a satisfaction questionnaire were linked to demographic and call-related dispatch data. Associations between the characteristics were analysed with multivariable logistic regression analysis with satisfaction as the dependent variable. A subgroup analysis was performed on callers for children aged between 0 and 4 years. RESULTS Of the 30 402 analysed callers, 73.0% were satisfied with the medical helpline. Satisfaction was associated with calling for a somatic injury (OR: 1.96, 95% CI: 1.72 to 2.23), receiving a face-to-face consultation (OR: 2.27, 95% CI: 2.04 to 2.50) and a waiting time less than 10 min (OR: 1.82, 95% CI: 1.56 to 2.08). Callers for a 0-year to 4-year-old patient were more likely to be satisfied when they called for a somatic illness or received a telephone consultation, compared with the rest of the population (p<0.0001). CONCLUSION Callers were in general satisfied with the medical helpline. Satisfaction was associated with reason for encounter, triage response and waiting time. People calling for 0-year to 4-year-old patients were, compared with the rest of the population, more frequently satisfied when they called for a somatic illness or received a telephone consultation.
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Affiliation(s)
- Nienke Doreen Zinger
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
- CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Stig Nikolaj Blomberg
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Freddy Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
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Whittaker W, Anselmi L, Nelson P, O'Donnell C, Ross N, Rothwell K, Hodgson D. Investigation of the demand for a 7-day (extended access) primary care service: an observational study from pilot schemes in England. BMJ Open 2019; 9:e028138. [PMID: 31492780 PMCID: PMC6731947 DOI: 10.1136/bmjopen-2018-028138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 07/29/2019] [Accepted: 08/01/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To understand how the uptake of an extended primary care service in the evenings and weekend varied by day of week and over time. Secondary objectives were to understand patient demographics of users of the service and how these varied by type of appointment and to core hour users. DESIGN Observational study. SETTING Primary care extended access appointments data in 13 centres in Greater Manchester, England, during 2016. PARTICIPANTS Appointments could be booked by 1 261 326 patients registered with a family practitioner in five Clinical Commissioning Group geographic areas. MAIN OUTCOME MEASURES Primary outcome measure was whether an appointment was used (booked and attended), secondary outcome measures included whether used appointments were prebooked or booked the same day, and delivered by a family or nurse practitioner. Additional analyses compared patient demographics with patients reporting the use of core hour primary care services. RESULTS 65.33% of 42 472 appointments were booked and attended (used). Usage of appointments was lowest on a Sunday at 46.73% (18.07 percentage points lower usage than on Mondays (95% CI -32.46 to -3.68)). Prebooked appointments were less likely to be booked among age group 0-9 and to result in patients not attending an appointment. Family practitioner appointments were increasingly less likely to be booked with age in comparison to nurse appointments. Patients attending extended access appointments tended to be younger in comparison to core hour patients. CONCLUSIONS There is spare capacity in the extended access service, particularly on Sundays, suggesting reconfigurations of the service may be needed to improve efficiency of delivering the service. Patient demographics suggest the service is used by a relatively younger population than core hour services. Patient demographics varied with the types of appointment provided, these findings may help healthcare providers improve usage by tailoring appointment provision to local populations.
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Affiliation(s)
- William Whittaker
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Laura Anselmi
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Pauline Nelson
- Alliance Manchester Business School, University of Manchester, Manchester, UK
- NIHR CLAHRC Greater Manchester, Manchester, UK
| | | | - Natalie Ross
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Damian Hodgson
- Alliance Manchester Business School, University of Manchester, Manchester, UK
- NIHR CLAHRC Greater Manchester, Manchester, UK
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Tan BYQ, Ngiam NJ, Chang ZY, Tan SMY, Shen X, Mok SF, Subramanian S, Ooi SBS, Kee ACL. Perceptions of a night float system for intern doctors in an internal medicine program: an Asian perspective. Korean J Med Educ 2019; 31:271-276. [PMID: 31455056 PMCID: PMC6715894 DOI: 10.3946/kjme.2019.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/14/2019] [Accepted: 06/24/2019] [Indexed: 06/10/2023]
Abstract
Long duty hours have been associated with significant medical errors, adverse events, and physician "burn-out". An innovative night float (NF) system has been implemented in our internal medicine program to reduce the negative effects of long duty hours associated with conventional full-call systems. However, concerns remain if this would result in inadequate training for interns. We developed a structured questionnaire to assess junior doctors' perceptions of the NF system compared to full calls, in areas of patient safety, medical training, and well-being. Ninety-seven (71%) of the 137 doctors polled responded. Ninety-one (94%) felt the NF system was superior to the full call system. A strong majority felt NF was beneficial for patient safety compared to full call (94% vs. 2%, p<0.001). The NF system was also perceived to reduce medical errors (94% vs. 2%, p<0.001) and reduce physician "burn-out" (95% vs. 5%, p<0.001). Beyond being a practical solution to duty-hour limitations, there was a significant perceived benefit of the NF system compared to the full call in terms of overall satisfaction, patient safety, reducing medical errors and physician "burn-out".
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Affiliation(s)
| | | | - Zi Yun Chang
- Department of Medicine, National University Health System, Singapore
| | | | - Xiayan Shen
- Department of Medicine, National University Health System, Singapore
| | - Shao Feng Mok
- Department of Medicine, National University Health System, Singapore
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Foster H, Macdonald S, Patterson C, O'Donnell CA. No such thing as bad publicity? A quantitative content analysis of print media representations of primary care out-of-hours services. BMJ Open 2019; 9:e023192. [PMID: 30910877 PMCID: PMC6475237 DOI: 10.1136/bmjopen-2018-023192] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore how out-of-hours primary healthcare services (OOHS) are represented in UK national newspapers, focusing on content and tone of reporting and the use of personal narratives to frame stories. DESIGN A retrospective cross-sectional quantitative content analysis of articles published in 2005, 2010 and 2015. DATA SOURCES Nexis database used to search 10 UK national newspapers covering quality, middle-market and tabloid publications. INCLUSION/EXCLUSION CRITERIA All articles containing the terms 'out-of-hours' (≥3 mentions per article) or ('NHS 24' OR 'NHS 111' OR 'NHS Direct') AND 'out-of-hours' (≥1 mention per article) were included. Letters, duplicate news items, opinion pieces and articles without a substantial portion of the story (>50% of an article's word count, as judged by researchers) concerning OOHS were excluded. RESULTS 332 newspaper articles were identified: 113 in 2005 (34.1%), 140 in 2010 (42.2%) and 79 in 2015 (23.8%). Of these, 195 (58.7%) were in quality newspapers, 99 (29.8%) in middle-market and 38 (11.3%) in tabloids. The most commonly reported themes were OOHS organisation, personal narratives and telephone triage. Stories about service-level crises and personal tragedy, including unsafe doctors and missed or delayed identification of rare conditions, predominated. The majority of articles (252, 75.9%) were negative in tone. This was observed for all included newspapers and by publication genre; middle-market newspapers had the highest percentage of negative articles (Pearson χ2=35.72, p<0.001). Articles presented little supporting contextual information, such as call rates per annum, or advice on how to access OOHS. CONCLUSION In this first reported analysis of UK national newspaper coverage of OOHS, media representation is generally negative in tone, with frequent reports of 'negative exemplars' of OOHS crises and fatal individual patient cases with little or no contextualisation. We present recommendations for the future reporting of OOHS, which could apply to the reporting of healthcare services more generally.
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Affiliation(s)
- Hamish Foster
- General Practice and Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Sara Macdonald
- General Practice and Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Chris Patterson
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Catherine A O'Donnell
- General Practice and Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
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Sutton E, Bion J, Aldridge C, Boyal A, Willars J, Tarrant C. Quality and safety of in-hospital care for acute medical patients at weekends: a qualitative study. BMC Health Serv Res 2018; 18:1015. [PMID: 30594209 PMCID: PMC6310936 DOI: 10.1186/s12913-018-3833-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The increased mortality risk associated with weekend admission to hospital (the 'weekend effect') has been reported across many health systems. More recently research has focused on causal mechanisms. Variations in the organisation and delivery of in-hospital care between weekends and weekdays have been identified, but this is not always to the detriment of weekend admissions, and the impact on mortality is uncertain. The insights of frontline staff and patients have been neglected. This article reports a qualitative study of patients and clinicians, to explore their views on quality and safety of care at weekends. METHODS We conducted focus groups and interviews with clinicians and patients with experience of acute medical care, recruited from three UK hospital Trusts. We analysed the data using a thematic analysis approach, aided by the use of NVivo, to explore quality and safety of care at weekends. RESULTS We held four focus groups and completed six in-depth interviews, with 19 clinicians and 12 patients. Four threats to quality and safety were identified as being more prominent at weekends, relating to i) the rescue and stabilisation of sick patients; ii) monitoring and responding to deterioration; iii) timely accurate management of the therapeutic pathway; iv) errors of omission and commission. CONCLUSIONS At weekends patients and staff are well aware of suboptimal staffing numbers, skill mix and access to resources at weekends, and identify that emergency admissions are prioritised over those already hospitalised. The consequences in terms of quality and safety and patient experience of care are undesirable. Our findings suggest the value of focusing on care processes and systems resilience over the weekends, and how these can be better supported, even in the limited resource environment that exists in many hospitals at weekends.
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Affiliation(s)
- Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Julian Bion
- University Hospitals Birmingham, Birmingham, UK
| | | | | | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
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Iezzoni LI, Wint AJ, Cluett WS, Ajayi T, Goudreau M, Blanchfield BB, Palmisano J, Tripodis Y. Early experiences with the Acute Community Care Program in eastern Massachusetts. Am J Manag Care 2018; 24:e270-e277. [PMID: 30222922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Emergency departments (EDs) frequently provide care for nonemergent health conditions outside of usual physician office hours. A nonprofit, fully integrated health insurer/care delivery system that enrolls socioeconomically disadvantaged adults with complex health needs partnered with an ambulance service provider to offer after-hours urgent care by specially trained and equipped paramedics in patients' residences. The Massachusetts Department of Public Health gave this initiative, the Acute Community Care Program (ACCP), a Special Project Waiver. We report results from its first 2 years of operation. STUDY DESIGN This was an observational study. METHODS We used descriptive methods to analyze administrative claims, financial and enrollment records from the health insurer, information from service logs submitted by ACCP paramedics, and self-reported patient perceptions from telephone surveys of ACCP recipients. RESULTS ACCP averaged only about 1 call per day in its first year, growing to about 2 visits daily in year 2. About 15% to 20% of ACCP patients ultimately were transported to EDs and between 7.2% and 17.1% were hospitalized within 1 day of their ACCP visits. No unexpected deaths occurred within 72 hours of ACCP visits. Paramedics stayed on scene approximately 80 minutes on average. About 70% of patients thought that ACCP spared them an ED visit; 90% or more were willing to receive future ACCP care. Average costs per ACCP visit fell from $844 in year 1 to $537 in year 2 as volumes increased. CONCLUSIONS This study using observational data provides preliminary evidence suggesting that ACCP might offer an alternative to EDs for after-hours urgent care. More rigorous evaluation is required to assess ACCP's effectiveness.
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Affiliation(s)
- Lisa I Iezzoni
- Mongan Institute Health Policy Center, Massachusetts General Hospital, 100 Cambridge St, Ste 1600, Boston, MA 02114.
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Reid LEM, Lone NI, Morrison ZJ, Weir CJ, Jones MC. The provision of seven day multidisciplinary staffing in Scottish acute medical units: a cross-sectional study. QJM 2018; 111:295-301. [PMID: 29408979 DOI: 10.1093/qjmed/hcy024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute medical units (AMUs) are a central component of the admission pathway for the majority of medical patients presenting to hospital in the United Kingdom and other international settings. Detail on multidisciplinary staffing provision on weekdays and weekends is lacking. Equity of staffing across 7 days is a strategic priority for national health services in the United Kingdom. AIM To evaluate weekday compared with weekend multidisciplinary staffing in a national set of AMUs. DESIGN Cross-sectional survey. METHODS Twenty-nine Scottish AMUs were identified and all were included in the study population. Data were collected by semi-structured interviews with nursing, pharmacy, therapy, non-consultant medical and consultant staff. Staffing was quantified in staff hours. A correction factor of 0.5 was applied to non-dedicated staff. The percentage of weekend/weekday staffing was calculated for each unit and the mean of these percentages was calculated to give a summary measure for each professional group. RESULTS As a percentage of weekday staffing levels, weekend staffing across the units was 93.8% for nursing staff; 2.2% for pharmacy staff; 13.1% for therapy staff; 69.6% for non-consultant staff and 65.0% for consultant staff. CONCLUSIONS There is a contrast between weekday and weekend staffing on the AMU, with reductions at weekends in total staff hours, the proportion of dedicated vs. undedicated staff and the seniority of nursing staff. The weekday/weekend difference was far more pronounced for allied healthcare professional staff than any other group. These findings have potential implications for patient outcomes, quality of care, hospital flow and workforce planning.
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Affiliation(s)
- L E M Reid
- Department of Development and Delivery, Ko Awatea Health Systems Innovation and Improvement, Middlemore Hospital, 54/100 Hospital Rd, Auckland 2025, New Zealand
- Quality, Research and Standards, Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh EH2 1JQ, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - N I Lone
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - Z J Morrison
- Business School, University of Aberdeen, Edward Wright Building, Dunbar Street, Aberdeen AB24 3QY, UK
| | - C J Weir
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
- Edinburgh Clinical Trials Unit, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - M C Jones
- Quality, Research and Standards, Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh EH2 1JQ, UK
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Affiliation(s)
- Cheryl Lim
- a Department of Paediatrics , St Mary's Hospital , London , UK
| | - Rahul Chodhari
- b Department of Paediatrics , Royal Free Hospital , London , UK
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Iacobucci G. Hunt promises affordable homes and flexible hours to retain NHS staff. BMJ 2017; 359:j4577. [PMID: 28974493 DOI: 10.1136/bmj.j4577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Haines TP, Bowles KA, Mitchell D, O’Brien L, Markham D, Plumb S, May K, Philip K, Haas R, Sarkies MN, Ghaly M, Shackell M, Chiu T, McPhail S, McDermott F, Skinner EH. Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials. PLoS Med 2017; 14:e1002412. [PMID: 29088237 PMCID: PMC5663333 DOI: 10.1371/journal.pmed.1002412] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/21/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Disinvestment (removal, reduction, or reallocation) of routinely provided health services can be difficult when there is little published evidence examining whether the services are effective or not. Evidence is required to understand if removing these services produces outcomes that are inferior to keeping such services in place. However, organisational imperatives, such as budget cuts, may force healthcare providers to disinvest from these services before the required evidence becomes available. There are presently no experimental studies examining the effectiveness of allied health services (e.g., physical therapy, occupational therapy, and social work) provided on weekends across acute medical and surgical hospital wards, despite these services being routinely provided internationally. The aim of this study was to understand the impact of removing weekend allied health services from acute medical and surgical wards using a disinvestment-specific non-inferiority research design. METHODS AND FINDINGS We conducted 2 stepped-wedge cluster randomised controlled trials between 1 February 2014 and 30 April 2015 among patients on 12 acute medical or surgical hospital wards spread across 2 hospitals. The hospitals involved were 2 metropolitan teaching hospitals in Melbourne, Australia. Data from n = 14,834 patients were collected for inclusion in Trial 1, and n = 12,674 in Trial 2. Trial 1 was a disinvestment-specific non-inferiority stepped-wedge trial where the 'current' weekend allied health service was incrementally removed from participating wards each calendar month, in a random order, while Trial 2 used a conventional non-inferiority stepped-wedge design, where a 'newly developed' service was incrementally reinstated on the same wards as in Trial 1. Primary outcome measures were patient length of stay (proportion staying longer than expected and mean length of stay), the proportion of patients experiencing any adverse event, and the proportion with an unplanned readmission within 28 days of discharge. The 'no weekend allied health service' condition was considered to be not inferior if the 95% CIs of the differences between this condition and the condition with weekend allied health service delivery were below a 2% increase in the proportion of patients who stayed in hospital longer than expected, a 2% increase in the proportion who had an unplanned readmission within 28 days, a 2% increase in the proportion who had any adverse event, and a 1-day increase in the mean length of stay. The current weekend allied health service included physical therapy, occupational therapy, speech therapy, dietetics, social work, and allied health assistant services in line with usual care at the participating sites. The newly developed weekend allied health service allowed managers at each site to reprioritise tasks being performed and the balance of hours provided by each professional group and on which days they were provided. Analyses conducted on an intention-to-treat basis demonstrated that there was no estimated effect size difference between groups in the proportion of patients staying longer than expected (weekend versus no weekend; estimated effect size difference [95% CI], p-value) in Trial 1 (0.40 versus 0.38; estimated effect size difference 0.01 [-0.01 to 0.04], p = 0.31, CI was both above and below non-inferiority margin), but the proportion staying longer than expected was greater with the newly developed service compared to its no weekend service control condition (0.39 versus 0.40; estimated effect size difference 0.02 [0.01 to 0.04], p = 0.04, CI was completely below non-inferiority margin) in Trial 2. Trial 1 and 2 findings were discordant for the mean length of stay outcome (Trial 1: 5.5 versus 6.3 days; estimated effect size difference 1.3 days [0.9 to 1.8], p < 0.001, CI was both above and below non-inferiority margin; Trial 2: 5.9 versus 5.0 days; estimated effect size difference -1.6 days [-2.0 to -1.1], p < 0.001, CI was completely below non-inferiority margin). There was no difference between conditions for the proportion who had an unplanned readmission within 28 days in either trial (Trial 1: 0.01 [-0.01 to 0.03], p = 0.18, CI was both above and below non-inferiority margin; Trial 2: -0.01 [-0.02 to 0.01], p = 0.62, CI completely below non-inferiority margin). There was no difference between conditions in the proportion of patients who experienced any adverse event in Trial 1 (0.01 [-0.01 to 0.03], p = 0.33, CI was both above and below non-inferiority margin), but a lower proportion of patients had an adverse event in Trial 2 when exposed to the no weekend allied health condition (-0.03 [-0.05 to -0.004], p = 0.02, CI completely below non-inferiority margin). Limitations of this research were that 1 of the trial wards was closed by the healthcare provider after Trial 1 and could not be included in Trial 2, and that both withdrawing the current weekend allied health service model and installing a new one may have led to an accommodation period for staff to adapt to the new service settings. Stepped-wedge trials are potentially susceptible to bias from naturally occurring change over time at the service level; however, this was adjusted for in our analyses. CONCLUSIONS In Trial 1, criteria to say that the no weekend allied health condition was non-inferior to current weekend allied health condition were not met, while neither the no weekend nor current weekend allied health condition demonstrated superiority. In Trial 2, the no weekend allied health condition was non-inferior to the newly developed weekend allied health condition across all primary outcomes, and superior for the outcomes proportion of patients staying longer than expected, proportion experiencing any adverse event, and mean length of stay. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12613001231730 and ACTRN12613001361796.
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Affiliation(s)
- Terry P. Haines
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
- * E-mail:
| | - Kelly-Ann Bowles
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Deb Mitchell
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
| | - Lisa O’Brien
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
- Department of Occupational Therapy, Monash University, Frankston, Victoria, Australia
| | - Donna Markham
- Monash Medical Centre, Allied Health, Monash Health, Clayton, Victoria, Australia
| | - Samantha Plumb
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kerry May
- Monash Medical Centre, Allied Health, Monash Health, Clayton, Victoria, Australia
| | - Kathleen Philip
- Department of Health and Human Services, Melbourne, Victoria, Australia
| | - Romi Haas
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
| | - Mitchell N. Sarkies
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Allied Health Research Unit, Monash Health, Cheltenham, Victoria, Australia
| | - Marcelle Ghaly
- Department of Physiotherapy, Footscray Hospital, Western Health, Footscray, Victoria, Australia
| | - Melina Shackell
- Department of Physiotherapy, Footscray Hospital, Western Health, Footscray, Victoria, Australia
| | - Timothy Chiu
- Footscray Hospital, Western Health, Footscray, Victoria, Australia
| | - Steven McPhail
- Institute of Biomedical Innovation, Queensland University of Technology and Centre for Functioning and Health Research, Buranda, Queensland, Australia
| | - Fiona McDermott
- Department of Social Work, Monash Medical Centre, Monash Health and Monash University, Clayton, Victoria, Australia
| | - Elizabeth H. Skinner
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
- Department of Physiotherapy, Footscray Hospital, Western Health, Footscray, Victoria, Australia
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Roberts CM, Lowe D, Skipper E, Steiner MC, Jones R, Gelder C, Hurst JR, Lowrey GE, Thompson C, Stone RA. Effect of time and day of admission on hospital care quality for patients with chronic obstructive pulmonary disease exacerbation in England and Wales: single cohort study. BMJ Open 2017; 7:e015532. [PMID: 28882909 PMCID: PMC5588982 DOI: 10.1136/bmjopen-2016-015532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To evaluate if observed increased weekend mortality was associated with poorer quality of care for patients admitted to hospital with chronic obstructive pulmonary disease (COPD) exacerbation. DESIGN Prospective case ascertainment cohort study. SETTING 199 acute hospitals in England and Wales, UK. PARTICIPANTS Consecutive COPD admissions, excluding subsequent readmissions, from 1 February to 30 April 2014 of whom 13 414 cases were entered into the study. MAIN OUTCOMES Process of care mapped to the National Institute for Health and Care Excellence clinical quality standards, access to specialist respiratory teams and facilities, mortality and length of stay, related to time and day of the week of admission. RESULTS Mortality was higher for weekend admissions (unadjusted OR 1.20, 95% CI 1.00 to 1.43), and for case-mix adjusted weekend mortality when calculated for admissions Friday morning through to Monday night (adjusted OR 1.19, 95% CI 1.00 to 1.43). Median time to death was 6 days. Some clinical processes were poorer on Mondays and during normal working hours but not weekends or out of hours. Specialist respiratory care was less available and less prompt for Friday and Saturday admissions. Admission to a specialist ward or high dependency unit was less likely on a Saturday or Sunday. CONCLUSIONS Increased mortality observed in weekend admissions is not easily explained by deficiencies in early clinical guideline care. Further study of out-of-hospital factors, specialty care and deaths later in the admission are required if effective interventions are to be made to reduce variation by day of the week of admission.
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Affiliation(s)
- Christopher Michael Roberts
- Barts Health, Queen Mary University of London, London, UK
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Derek Lowe
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Emma Skipper
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Michael C Steiner
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Respiratory Biomedical Sciences Research Unit, Institute for Lung Health, Glenfield Hospital NHS Trust, Leicester, Leicestershire, United Kingdom
| | - Rupert Jones
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Clinical Trials & Health Research - Institute of Translational & Stratified Medicine, Plymouth University, Plymouth, Devon, United Kingdom
| | - Colin Gelder
- Department of respiratory medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Warwickshire, United Kingdom
| | - John R Hurst
- UCL Respiratory, University College London, London, London, United Kingdom
| | - Gillian E Lowrey
- Department of respiratory medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, Derbyshire, United Kingdom
| | | | - Robert A Stone
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Somerset Lung Centre, Musgrove Park Hospital, Taunton, Somerset, UK
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van der Biezen M, Wensing M, Poghosyan L, van der Burgt R, Laurant M. Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study. BMC Health Serv Res 2017; 17:589. [PMID: 28830410 PMCID: PMC5568365 DOI: 10.1186/s12913-017-2548-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours. METHODS A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus group discussions. Data was collected between June, 2014 and October, 2015 at an out-of-hours primary care organisation in the Netherlands. Overall, 38 health professionals (GPs, NPs, and support staff) participated in the study. The interviews were audio-taped and transcribed verbatim. Two researchers conducted an inductive content analysis, involving the identification of relevant items in a first phase and clustering into themes in a second phase. RESULTS The following four themes emerged from the data: clarity of NP role and regulation, shared caseload and use of skills, communication concerning professional roles, trust and support in NP practice. Main factors influencing collaboration between GPs and NPs included a lack of knowledge regarding the NPs' scope of practice and regulations governing NP role; differences in teams in sharing caseload and using each other's skills effectively; varying support of GPs for the NP role; and limited communication between GPs and NPs regarding professional roles during the shift. Lack of collaboration was perceived to result in an increased risk of delay for patients who needed treatment from a GP, especially in teams with more NPs. Collaboration was not perceived to improve over time as teams varied across shifts. CONCLUSION In out-of-hours primary care teams constantly change and team members are often unfamiliar with each other or other's competences. In this environment, knowledge and communication about team members' roles is continuously at stake. Especially in teams with more NPs, team members need to use each other's skills to deliver care to all patients on time.
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Affiliation(s)
- Mieke van der Biezen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Health Services Research and Implementation Science, Heidelberg University, Marsilius Arkaden-Turm West, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Lusine Poghosyan
- Columbia University School of Nursing, 168th St., Suite 219, New York, NY 10032 USA
| | - Regi van der Burgt
- Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, 5652 NP, Eindhoven, The Netherlands
| | - Miranda Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, IQ Healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, P.O. BOX 6960, Nijmegen, 6503 GL The Netherlands
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Iacobucci G. Patients being put at risk from unfilled out-of-hours shifts, GPs warn. BMJ 2017; 358:j3893. [PMID: 28811284 DOI: 10.1136/bmj.j3893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lemire F. Fatigue risk management revisited. Can Fam Physician 2017; 63:656. [PMID: 28807966 PMCID: PMC5555338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Rimmer A. Rising indemnity fees could lead to worst ever winter crisis, says new GP leader. BMJ 2017; 358:j3682. [PMID: 28765123 DOI: 10.1136/bmj.j3682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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van der Biezen M, Wensing M, van der Burgt R, Laurant M. Towards an optimal composition of general practitioners and nurse practitioners in out-of-hours primary care teams: a quasi-experimental study. BMJ Open 2017; 7:e015509. [PMID: 28559458 PMCID: PMC5730011 DOI: 10.1136/bmjopen-2016-015509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To gain insights into the ability of general practitioners (GPs) and nurse practitioners (NPs) to meet patient demands in out-of-hours primary care by comparing the outcomes of teams with different ratios of practitioners. DESIGN Quasi-experimental study. SETTING A GP cooperative (GPC) in the Netherlands. INTERVENTION Team 2 (1 NP, 3 GPs) and team 3 (2 NPs, 2 GPs) were compared with team 1 (4 GPs). Each team covered 35 weekend days. PARTICIPANTS All 9503 patients who were scheduled for a consultation at the GPC through a nurse triage system. OUTCOME MEASURES The primary outcome was the total number of consultations per provider for weekend cover between 10:00 and 18:00 hours. Secondary outcomes concerned the numbers of patients outside the NPs' scope of practice, patient safety, resource use, direct healthcare costs and GPs' performance. RESULTS The mean number of consultations per shift was lower in teams with NPs (team 1: 93.9, team 3: 87.1; p<0.001). The mean proportion of patients outside NPs' scope of practice per hour was 9.0% (SD 6.7), and the highest value in any hour was 40%. The proportion of patients who did not receive treatment within the targeted time period was higher in teams with NPs (team 2, 5.2%; team 3, 8.3%) compared with GPs only (team 1 3.5%) (p<0.01). Team 3 referred more patients to the emergency department (14.7%) compared with team 1 (12.0%; p=0.028). In teams with NPs, GPs more often treated urgent patients (team 1: 13.2%, team 2: 16.3%, team 3: 21.4%; p<0.01) and patients with digestive complaints (team 1: 11.1%, team 2: 11.8%, team 3: 16.7%; p<0.01). CONCLUSIONS Primary healthcare teams with a ratio of up to two GPs and two NPs provided sufficient capacity to provide care to all patients during weekend cover. Areas of concern are the number of consultations, delay in patient care and referrals to the emergency department. TRIAL REGISTRATION NCT02407847.
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Affiliation(s)
- Mieke van der Biezen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University, Heidelberg, Germany
| | - Regi van der Burgt
- Foundation for Development of Quality Care in General Practice, Eindhoven, The Netherlands
| | - Miranda Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, The Netherlands
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Tarrant C, Sutton E, Angell E, Aldridge CP, Boyal A, Bion J. The 'weekend effect' in acute medicine: a protocol for a team-based ethnography of weekend care for medical patients in acute hospital settings. BMJ Open 2017; 7:e016755. [PMID: 28385913 PMCID: PMC5719649 DOI: 10.1136/bmjopen-2017-016755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION It is now well-recognised that patients admitted to hospital on weekends are at higher risk of death than those admitted during weekdays. However, the causes of this 'weekend effect' are poorly understood. Some contend that there is a deficit of medical staff on weekends resulting in poorer quality care, whereas others find that patients admitted to hospital on weekends are sicker and therefore at higher risk of adverse outcomes. Clarifying the causal pathway is clearly important in order to identify effective solutions. In this article we describe an ethnographic approach to evaluating the organisation and delivery of medical care on weekends compared with weekdays, with a specific focus on the role of medical staff as part of National Health Service England's plan to implement 7-day services. METHODS AND ANALYSIS We will conduct an ethnographic study of 20 acute hospitals in England between April 2016 and March 2018 as part of the High-intensity Specialist-Led Acute Care project (www.hislac.org). Data will be collected through observations and shadowing, and interviews with staff, in 10 hospitals with higher intensity specialist (consultant) staffing on weekends and 10 with lower intensity specialist staffing. Interviews will be conducted with up to 20 patients sampled from two high-intensity and two low-intensity sites. We will coordinate, compare and contrast observations across our team of ethnographers. Analysis will be both in-depth and cross-cutting, exploring specific features within individual sites and making comparisons between them. We outline how data collection and analysis will be facilitated and organised. ETHICS AND DISSEMINATION The project has received ethics approval from the South West Wales Research Ethics Committee: Reference 13/WA/0372. Informed consent will be obtained for all interview participants. The findings will be disseminated through peer-reviewed publications in high-quality journals and at national and international conferences.
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Affiliation(s)
- Carolyn Tarrant
- University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK
| | - Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Angell
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Amunpreet Boyal
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
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Abstract
Interest in nephrology has been declining in recent years. Long work hours and a poor work/life balance may be partially responsible, and may also affect a fellowship's educational mission. We surveyed nephrology program directors using a web-based survey in order to define current clinical and educational practice patterns and identify areas for improvement. Our survey explored fellowship program demographics, fellows' workload, call structure, and education. Program directors were asked to estimate the average and maximum number of patients on each of their inpatient services, the number of patients seen by fellows in clinic, and to provide details regarding their overnight and weekend call. In addition, we asked about number of and composition of didactic conferences. Sixty-eight out of 148 program directors responded to the survey (46%). The average number of fellows per program was approximately seven. The busiest inpatient services had a mean of 21.5±5.9 patients on average and 33.8±10.7 at their maximum. The second busiest services had an average and maximum of 15.6±6.0 and 24.5±10.8 patients, respectively. Transplant-only services had fewer patients than other service compositions. A minority of services (14.5%) employed physician extenders. Fellows most commonly see patients during a single weekly continuity clinic, with a typical fellow-to-faculty ratio of 2:1. The majority of programs do not alter outpatient responsibilities during inpatient service time. Most programs (approximately 75%) divided overnight and weekend call responsibilities equally between first year and more senior fellows. Educational practices varied widely between programs. Our survey underscores the large variety in workload, practice patterns, and didactics at different institutions and provides a framework to help improve the service/education balance in nephrology fellowships.
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Affiliation(s)
- Scott E Liebman
- Department of Medicine, Division of Nephrology, University of Rochester Medical Center, Rochester, New York
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Stern G. Integrated Call System Bridges Gap between HTM and IT. Biomed Instrum Technol 2017; 51:265-268. [PMID: 28530865 DOI: 10.2345/0899-8205-51.3.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Heutmekers M, Naaldenberg J, Frankena TK, Smits M, Leusink GL, Assendelft WJJ, van Schrojenstein Lantman-de Valk HMJ. After-hours primary care for people with intellectual disabilities in The Netherlands-Current arrangements and challenges. Res Dev Disabil 2016; 59:1-7. [PMID: 27484922 DOI: 10.1016/j.ridd.2016.07.007] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 06/29/2016] [Accepted: 07/12/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Little is known about the organisation of after-hours primary care for people with intellectual disabilities (ID), and mainstream care is not self-evidently accessible or fit for this group. A first step towards improvement is a greater understanding of current after-hours primary ID care. AIMS This study explores the organisation of and experiences with after-hours primary care provided for people with ID in The Netherlands. METHODS AND PROCEDURES A telephone survey amongst 68 care provider services including questions on organisational characteristics, problem areas, facilitators, and inhibitors. OUTCOMES AND RESULTS A multitude of different after-hours primary care arrangements were found. Primary care physicians (PCPs) were involved in almost all care provider services, often in alliance with PCP cooperatives. Specialised ID physicians had differing roles as gatekeeper, primary caregiver, or consultant. Most problems during the after-hours arose regarding daily care professionals' competences. Facilitators and inhibitors of after-hours primary care were themed around complexity of, and need for, specialised care, multidisciplinary team of professionals, communication and information, and prerequisites at organisational level. CONCLUSIONS AND IMPLICATIONS Evidence on specific after-hours health needs of people with ID is needed to strengthen collaboration between specialist ID care services and mainstream healthcare services to adequately provide care.
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Affiliation(s)
- Marloes Heutmekers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Jenneken Naaldenberg
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Tessa K Frankena
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Marleen Smits
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Geraline L Leusink
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Willem J J Assendelft
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Barry HE, Campbell JL, Asprey A, Richards SH. The use of patient experience survey data by out-of-hours primary care services: a qualitative interview study. BMJ Qual Saf 2016; 25:851-859. [PMID: 26490004 PMCID: PMC5136714 DOI: 10.1136/bmjqs-2015-003963] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 09/16/2015] [Accepted: 10/04/2015] [Indexed: 11/13/2022]
Abstract
BACKGROUND English National Quality Requirements mandate out-of-hours primary care services to routinely audit patient experience, but do not state how it should be done. OBJECTIVES We explored how providers collect patient feedback data and use it to inform service provision. We also explored staff views on the utility of out-of-hours questions from the English General Practice Patient Survey (GPPS). METHODS A qualitative study was conducted with 31 staff (comprising service managers, general practitioners and administrators) from 11 out-of-hours primary care providers in England, UK. Staff responsible for patient experience audits within their service were sampled and data collected via face-to-face semistructured interviews. RESULTS Although most providers regularly audited their patients' experiences by using patient surveys, many participants expressed a strong preference for additional qualitative feedback. Staff provided examples of small changes to service delivery resulting from patient feedback, but service-wide changes were not instigated. Perceptions that patients lacked sufficient understanding of the urgent care system in which out-of-hours primary care services operate were common and a barrier to using feedback to enable change. Participants recognised the value of using patient experience feedback to benchmark services, but perceived weaknesses in the out-of-hours items from the GPPS led them to question the validity of using these data for benchmarking in its current form. CONCLUSIONS The lack of clarity around how out-of-hours providers should audit patient experience hinders the utility of the National Quality Requirements. Although surveys were common, patient feedback data had only a limited role in service change. Data derived from the GPPS may be used to benchmark service providers, but refinement of the out-of-hours items is needed.
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Affiliation(s)
- Heather E Barry
- University of Exeter Medical School, University of Exeter, Exeter, Devon, UK
| | - John L Campbell
- University of Exeter Medical School, University of Exeter, Exeter, Devon, UK
| | - Anthea Asprey
- University of Exeter Medical School, University of Exeter, Exeter, Devon, UK
| | - Suzanne H Richards
- University of Exeter Medical School, University of Exeter, Exeter, Devon, UK
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Keast K. NURSE PRACTITIONERS TAKING URGENT CARE OF PERTH. Aust Nurs Midwifery J 2016; 24:22. [PMID: 29251460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
From chronic disease management to emergency care, Nurse Practitioners (NPs) have been redefining the face of health care in Australia since 2000. While the role continues to remain a largely untapped health solution, two endorsed nurse practitioners are treading their own career path with an innovative venture.
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Auer S, Berger J, Staeger P. [Not Available]. Praxis (Bern 1994) 2016; 105:1125-1131. [PMID: 27650898 DOI: 10.1024/1661-8157/a002473] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Zusammenfassung. Hausbesuche sind eine wichtige Tätigkeit der Hausärzte. Diese Dienstleistung zugunsten der Öffentlichkeit wird unter schwierigen Bedingungen mit wenig Mitteln ausgeübt. Der Artikel beschreibt einen Notfallkoffer für Ärzte, die von einer Telefontriage profitieren und bei Bedarf auf einen professionellen Rettungsdienst zurückgreifen können. Der Inhalt des Notfallkoffers sollte den Ärzten helfen, die häufigsten Probleme bei Hausbesuchen in städtischen Gebieten und ihren Agglomerationen zu lösen.
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Affiliation(s)
- Silva Auer
- 1 Centre de médecine générale, Policlinique médicale universitaire, Lausanne
| | - Jérôme Berger
- 2 Centre de pharmacie communautaire, Policlinique médicale universitaire, Lausanne
| | - Philippe Staeger
- 1 Centre de médecine générale, Policlinique médicale universitaire, Lausanne
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Ha HJ, Han KT, Kim SJ, Sohn TY, Jeon B, Park EC. Changes in Saturday outpatient volume and billings after introducing the Saturday incentive programme to clinics in South Korea: a longitudinal cohort study using claims data from 2012 to 2014. BMJ Open 2016; 6:e011248. [PMID: 27288380 PMCID: PMC4908875 DOI: 10.1136/bmjopen-2016-011248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/29/2022] Open
Abstract
OBJECTIVE In October 2013, the South Korean government introduced an incentive programme to increase the availability of Saturday treatment at clinics, hoping to increase the role of primary care providers as gatekeepers to medical care. To the best of our knowledge, no one has yet investigated this programme's effect on overall outpatient care. Our study aims to analyse the change in Saturday outpatient volume and billings in clinics that adopted the Saturday incentive programme. SETTING Our study used 3 types of data from the period October 2012 to March 2014: National Health Insurance Service (NHIS) claims data, hospital evaluation data and medical institution data. PARTICIPANTS These data consisted of 66 825 881 outpatient cases from 2837 clinics. INTERVENTIONS Introducing the Saturday incentive programme. OUTCOME MEASURE We performed a multilevel analysis that adjusted for clinic-level and outpatient-level variables to examine the difference in the percentage of Saturday outpatient volume and billings after introducing the Saturday incentive programme. RESULTS The percentages of Saturday outpatient volume and billings were higher after introducing the programme (outpatient volume: β=2.065, p<0.001; outpatient billings: β=3.518, p<0.001). In addition, outpatient volume and billings on Friday and Saturday increased after introducing the programme, while those on weekdays, excluding Friday, decreased. CONCLUSIONS Our findings suggest that the Saturday incentive programme has affected clinic outpatient care and is a worthwhile health policy in terms of promoting primary care. Thus, it may improve healthcare accessibility and quality of care, and prevent inappropriate usage such as emergency room visits by providing patients with weekend clinic hours.
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Affiliation(s)
- Hyun Ji Ha
- Department of Health Policy and Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
- Health Insurance Review and Assessment Service, Seoul, Republic of Korea
| | - Kyu-Tae Han
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, Soonchunhyang University, Asan, Republic of Korea
| | - Tae Yong Sohn
- Department of Health Services Administration, Yuhan University, Bucheon, Republic of Korea
| | - Byungyool Jeon
- Department of Preventive Medicine, CHA University College of Medicine, Pocheon, Republic of Korea
| | - Eun-Cheol Park
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Rimmer A. BMA must keep up campaign on seven day services, president says. BMJ 2016; 353:i2534. [PMID: 27151965 DOI: 10.1136/bmj.i2534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Knight HE, van der Meulen JH, Gurol-Urganci I, Smith GC, Kiran A, Thornton S, Richmond D, Cameron A, Cromwell DA. Birth "Out-of-Hours": An Evaluation of Obstetric Practice and Outcome According to the Presence of Senior Obstetricians on the Labour Ward. PLoS Med 2016; 13:e1002000. [PMID: 27093698 PMCID: PMC4836717 DOI: 10.1371/journal.pmed.1002000] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 03/10/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Concerns have been raised that a lack of senior obstetricians ("consultants") on the labour ward outside normal hours may lead to worse outcomes among babies born during periods of reduced cover. METHODS AND FINDINGS We carried out a multicentre cohort study using data from 19 obstetric units in the United Kingdom between 1 April 2012 and 31 March 2013 to examine whether rates of obstetric intervention and outcome change "out-of-hours," i.e., when consultants are not providing dedicated, on-site labour ward cover. At the 19 hospitals, obstetric rotas ranged from 51 to 106 h of on-site labour ward cover per week. There were 87,501 singleton live births during the year, and 55.8% occurred out-of-hours. Women who delivered out-of-hours had slightly lower rates of intrapartum caesarean section (CS) (12.7% versus 13.4%, adjusted odds ratio [OR] 0.94; 95% confidence interval [CI] 0.90 to 0.98) and instrumental delivery (15.6% versus 17.0%, adj. OR 0.92; 95% CI 0.89 to 0.96) than women who delivered at times of on-site labour ward cover. There was some evidence that the severe perineal tear rate was reduced in out-of-hours vaginal deliveries (3.3% versus 3.6%, adj. OR 0.92; 95% CI 0.85 to 1.00). There was no evidence of a statistically significant difference between out-of-hours and "in-hours" deliveries in the rate of babies with a low Apgar score at 5 min (1.33% versus 1.25%, adjusted OR 1.07; 95% CI 0.95 to 1.21) or low cord pH (0.94% versus 0.82%; adjusted OR 1.12; 95% CI 0.96 to 1.31). Key study limitations include the potential for bias by indication, the reliance upon an organisational measure of consultant presence, and a non-random sample of maternity units. CONCLUSIONS There was no difference in the rate of maternal and neonatal morbidity according to the presence of consultants on the labour ward, with the possible exception of a reduced rate of severe perineal tears in out-of-hours vaginal deliveries. Fewer women had operative deliveries out-of-hours. Taken together, the available evidence provides some reassurance that the current organisation of maternity care in the UK allows for good planning and risk management. However there is a need for more robust evidence on the quality of care afforded by different models of labour ward staffing.
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Affiliation(s)
- Hannah E. Knight
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- * E-mail:
| | - Jan H. van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gordon C. Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom
| | - Amit Kiran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Steve Thornton
- Department of Obstetrics and Gynaecology, University of Exeter Medical School, Exeter, United Kingdom
| | - David Richmond
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - Alan Cameron
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - David A. Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Abstract
In this Perspective on the study by Hannah Knight and colleagues, Jenny Myers and Edward Johnstone consider the implications of negative findings in a variable setting in which adverse events are rare.
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Affiliation(s)
- Jenny E. Myers
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Edward D. Johnstone
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, United Kingdom
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Boone MD, Massa J, Mueller A, Jinadasa SP, Lee J, Kothari R, Scott DJ, Callahan J, Celi LA, Hacker MR. The organizational structure of an intensive care unit influences treatment of hypotension among critically ill patients: A retrospective cohort study. J Crit Care 2016; 33:14-8. [PMID: 26975737 DOI: 10.1016/j.jcrc.2016.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/04/2016] [Accepted: 02/10/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Prior studies report that weekend admission to an intensive care unit is associated with increased mortality, potentially attributed to the organizational structure of the unit. This study aims to determine whether treatment of hypotension, a risk factor for mortality, differs according to level of staffing. METHODS Using the Multiparameter Intelligent Monitoring in Intensive Care database, we conducted a retrospective study of patients admitted to an intensive care unit at Beth Israel Deaconess Medical Center who experienced one or more episodes of hypotension. Episodes were categorized according to the staffing level, defined as high during weekday daytime (7 am-7 pm) and low during weekends or nighttime (7 pm-7 am). RESULTS Patients with a hypotensive event on a weekend were less likely to be treated compared with those that occurred during the weekday daytime (P = .02). No association between weekday daytime vs weekday nighttime staffing levels and treatment of hypotension was found (risk ratio, 1.02; 95% confidence interval, 0.98-1.07). CONCLUSION Patients with a hypotensive event on a weekend were less likely to be treated than patients with an event during high-staffing periods. No association between weekday nighttime staffing and hypotension treatment was observed. We conclude that treatment of a hypotensive episode relies on more than solely staffing levels.
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Affiliation(s)
- M Dustin Boone
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Jennifer Massa
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Ariel Mueller
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Sayuri P Jinadasa
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Joon Lee
- Division of Health Sciences and Technology, Harvard-Massachusetts Institute of Technology, Cambridge, MA; School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | | | - Daniel J Scott
- Division of Health Sciences and Technology, Harvard-Massachusetts Institute of Technology, Cambridge, MA
| | - Julie Callahan
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, MA
| | - Leo Anthony Celi
- Division of Health Sciences and Technology, Harvard-Massachusetts Institute of Technology, Cambridge, MA
| | - Michele R Hacker
- Harvard Medical School, Boston, MA; Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA.
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Nazar H, Nazar Z, Simpson J, Yeung A, Whittlesea C. Summative service and stakeholder evaluation of an NHS-funded community Pharmacy Emergency Repeat Medication Supply Service (PERMSS). BMJ Open 2016; 6:e009736. [PMID: 26787252 PMCID: PMC4735177 DOI: 10.1136/bmjopen-2015-009736] [Citation(s) in RCA: 6] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Service and stakeholder evaluation of an NHS-funded service providing out-ofhours (OOH) emergency repeat medications to patients self-presenting at community pharmacies. SETTING Community pharmacies across the North East of England accredited to provide this service. PARTICIPANTS Patients self-presenting to community pharmacies during OOH periods with emergency repeat medication supply requests. INTERVENTION Community pharmacists assessed each request for clinical appropriateness and when suitable provide an emergency repeat medication supply, with additional pharmaceutical advice and services if required. PRIMARY OUTCOMES Number of emergency repeat medication supplies, time of request, reason for access, medication(s), pharmaceutical advice and services provided. Secondary outcomes were community pharmacist and patient satisfaction. RESULTS A total of 2485 patients were managed across 227 community pharmacies (15 December 2014 to 7 April 2015). Most patients presented on Saturdays, with increased activity over national holidays. Older age was associated with increased service use. Of the 3226 medications provided, 439 were classified as high risk. Patients found this service easy to access and were willing to access the community pharmacy in the future for medication-related issues. In the absence of this service, 50% of patients would have missed their medication(s) until they saw their doctor and a further 46% would have accessed an alternative service. The cost of National Health Service (NHS) service(s) for patients who would have accessed an alternative OOH service was estimated as 37 times that of the community pharmacy service provided. Community pharmacists were happy to provide this service despite increased consultation times and workload. CONCLUSIONS Community pharmacists were able to manage patients' OOH requests for emergency repeat medication and patients were happy with the service provided. Since the service cost was favourable when compared with alternative OOH services, it would be a viable option to reduce the workload on the wider NHS.
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Affiliation(s)
- Hamde Nazar
- School of Medicine, Pharmacy and Health, Durham University, Stockton-On-Tees, UK
| | - Zachariah Nazar
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Jill Simpson
- Clinical Strategy, NHS England North—Cumbria and the North East, Durham, UK
| | - Andre Yeung
- Senior Specialist Pharmacist Advisor, Northumberland, Tyne and Wear Local Pharmacy Network, Northumberland, UK
| | - Cate Whittlesea
- School of Medicine, Pharmacy and Health, Durham University, Stockton-On-Tees, UK
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Iacobucci G. Wider group of health professionals should be located in emergency departments, college says. BMJ 2016; 352:i15. [PMID: 26728883 DOI: 10.1136/bmj.i15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Iacobucci G. Flagship "seven day working" hospital doesn't provide full seven day service, doctors say. BMJ 2015; 351:h6842. [PMID: 26671476 DOI: 10.1136/bmj.h6842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kmietowicz Z. Emergency care specialists renew call for out-of-hours services to be located in hospitals. BMJ 2015; 351:h5932. [PMID: 26537914 DOI: 10.1136/bmj.h5932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hawkes N. Emergency departments should provide range of out-of-hours services, conference hears. BMJ 2015; 351:h5080. [PMID: 26399260 DOI: 10.1136/bmj.h5080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ruge T, Ekelund U. [Great need for emergency physicians on call time]. Lakartidningen 2015; 112:DMEL. [PMID: 26305902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Toralph Ruge
- Kirurgi och Perioperativ vetenskap - Akutsjukvård Umeå, Sweden Kirurgi och Perioperativ vetenskap - Akutsjukvård Umeå, Sweden
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Meacock R, Doran T, Sutton M. What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions? Health Econ 2015; 24:907-912. [PMID: 26010243 DOI: 10.1002/hec.3207] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [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: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 06/04/2023]
Abstract
The English National Health Service is moving towards providing comprehensive 7-day hospital services in response to higher death rates for emergency weekend admissions. Using Hospital Episode Statistics between 1st April 2010 and 31st March 2011 linked to all-cause mortality within 30 days of admission, we estimate the number of excess deaths and the loss in quality-adjusted life years associated with emergency weekend admissions. The crude 30-day mortality rate was 3.70% for weekday admissions and 4.05% for weekend admissions. The excess weekend death rate equates to 4355 (risk adjusted 5353) additional deaths each year. The health gain of avoiding these deaths would be 29 727-36 539 quality-adjusted life years per year. The estimated cost of implementing 7-day services is £1.07-£1.43 bn, which exceeds by £339-£831 m the maximum spend based on the National Institute for Health and Care Excellence threshold of £595 m-£731 m. There is as yet no clear evidence that 7-day services will reduce weekend deaths or can be achieved without increasing weekday deaths. The planned cost of implementing 7-day services greatly exceeds the maximum amount that the National Health Service should spend on eradicating the weekend effect based on current evidence. Policy makers and service providers should focus on identifying specific service extensions for which cost-effectiveness can be demonstrated.
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Affiliation(s)
- Rachel Meacock
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Matt Sutton
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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Iacobucci G. Hunt promises more transparency and fewer targets in "more human" NHS. BMJ 2015; 351:h3885. [PMID: 26187527 DOI: 10.1136/bmj.h3885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Due-Christensen M, Kaldan G, Almdal TP, Glindorf M, Nielsen KE, Zoffmann V. Out-of-office hours nurse-driven acute telephone counselling service in a large diabetes outpatient clinic: A mixed methods evaluation. Patient Educ Couns 2015; 98:890-894. [PMID: 25846192 DOI: 10.1016/j.pec.2015.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/28/2015] [Accepted: 03/13/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To map the usage of out-of-office hours acute telephone counselling (ATC) provided by diabetes specialist nurses (n=18) for diabetes patients to explore potentials for improvement. METHODS A mixed methods study involved mapping of ATC-usage during 6 months and a retrospective audit of frequent users. RESULTS Altogether, 3197 calls were registered that were related to 592 individual patients, corresponding to 10% of the population. Proportionally more users suffered from type 1 diabetes (p<0.001). ATC-users' mean HbA1c was 8.8% (73 mmol/mol) compared to 8.1% (65 mmol/mol) for all patients attending the clinic (p<0.001). Hyperglycaemia was the most frequent reason for calling. The use of ATC likely prevented 15 admissions. More than half of the calls came from general nurses based in the community (n=619) and general nurses and nursing assistants based in care homes (n=1018). The majority (75%) of patients called less than five times. However, 8% called 16 times or more accounting for 52% of all calls. A retrospective audit identified them as physically and/or psychologically fragile patients. CONCLUSION Hyperglycaemia was the most frequent reason for calling, and insulin dose adjustment the most frequent advice given. PRACTICE IMPLICATIONS Frequent users identified need additional support.
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Affiliation(s)
- Mette Due-Christensen
- Steno Diabetes Center, Gentofte, Denmark; Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK.
| | - Gudrun Kaldan
- Steno Diabetes Center, Gentofte, Denmark; Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hilleroed, Denmark
| | - Thomas P Almdal
- Steno Diabetes Center, Gentofte, Denmark; Department of Endocrinology, Gentofte University Hospital, Gentofte, Denmark
| | | | | | - Vibeke Zoffmann
- Steno Diabetes Center, Gentofte, Denmark; Research Unit Women's and Children's Health, Rigshospitalet University Hospital, Copenhagen, Denmark
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Moberly T. Half of public think weekend access to GPs should be NHS priority. BMJ 2015; 350:h3464. [PMID: 26109293 DOI: 10.1136/bmj.h3464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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