Trends in use of health care services in Swedish primary care district. A ten year perspective.

In a study that covered ten years a questionnaire about use of health care facilities was mailed each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district with three health centres. Primary care was the health care form with the greatest contact area with the population studied. However, the strengthening of district physician resources at one of the three health centres did not, in the long term, lead to more people coming into contact with this form of medical care. It was more common for those who visited a private doctor or school/company doctor also to consult a district physician than vice versa. Similarly, hospital patients visited the health centre to a greater degree than patients of health centres visited hospitals. The only long-term change in the flow of patients that could be registered was a reduction in the number of patients who visited hospital emergency departments. It is concluded that the implementation of an annual survey may be considerably more helpful than more sparse investigations in distinguishing between temporary fluctuations and real changes.     

High hospital readmission rates for patients aged ≥65 years associated with low socioeconomic status in a Swedish region: a cross-sectional study in primary care

Objective: There is a presumption that hospital readmission rates amongst persons aged ≥65 years are mainly dependent on the quality of care. In this study, our primary aim was to explore the association between 30-day hospital readmission for patients aged ≥65 years and socioeconomic characteristics of the studied population. A secondary aim was to explore the association between self-reported lack of strategies for working with older patients at primary health care centres and early readmission.

Design: A cross-sectional ecological study and an online questionnaire sent to the heads of the primary health care centres. We performed correlation and regression analyses.

Setting and subjects: Register data of 283,063 patients in 29 primary health care centres in the Region Örebro County (Sweden) in 2014.

Main outcome measure: Thirty-day hospital readmission rates for patients aged ≥65 years. Covariates were socioeconomic characteristics among patients registered at the primary health care centre and eldercare workload.

Results: Early hospital readmission was found to be associated with low socioeconomic status of the studied population: proportion foreign-born (r?=?0.74; p?r?=?0.73; p?r?=?0.74; p?r?=?0.51; p?r?=??0.40; p?=?0.03). The proportion of unemployed alone could explain up to 71.4% of the variability in hospital readmission (p?Conclusion: Primary health care centres localized in neighbourhoods with low socioeconomic status had higher rates of hospital readmission for patients aged ≥65. Interventions aimed at reducing hospital readmissions for older patients should also consider socioeconomic disparities.

• Key Points

• In Sweden, hospital readmission within 30 days among patients aged ≥65 has been used as a measure of quality of primary care for the elderly.

• However, in our study, elderly 30-day readmission was associated with low neighbourhood socioeconomic status.

• A simple survey in one Swedish region showed that the primary health care centres that lacked active strategies for working with aged patients did not have higher hospital readmission rates than those that reported having strategies.

• Interventions aimed at reducing elderly hospital readmissions should therefore also consider the socioeconomic disparities in the elderly.

     

Generalised anxiety disorder symptoms and utilisation of health care services. A cross-sectional study from the “Northern Finland 1966 Birth Cohort”

Objective: To analyse the utilization of health care services of people who tested positive for GAD compared to those who tested negative. Setting: A cross-sectional study from the Northern Finland 1966 Birth Cohort. Subjects: A total of 10,282 members followed from birth in a longitudinal study were asked to participate in a follow-up survey at the age of 46. As part of this survey they filled in questionnaries concerning health care utilization and their illness history as well as the GAD-7 screening tool. Althogether 5,480 cohort members responded to the questionnaries. Main outcome measures: Number of visits in different health care services among people who tested positive for GAD with the GAD-7 screening tool compared to those who tested negative. Results: People who tested positive for GAD had 112% more total health care visits, 74% more total physician visits, 115% more visits to health centres, 133% more health centre physician visits, 160% more visits to secondary care, and 775% more mental health care visits than those who tested negative. Conclusion: People with GAD symptoms utilize health care services more than other people.

• Key Points

• Generalised anxiety disorder (GAD) is a common but poorly identified mental health problem in primary care.

• People who tested positive for GAD utilise more health care services than those who tested negative.

• About 58% of people who tested positive for GAD had visited their primary care physician during the past year.

• Only 29% of people who tested positive for GAD had used mental health services during the past year.

     

Oral anticoagulant treatment in a medical care district - A descriptive study

Objective - To describe how oral anticoagulant therapy is performed in a defined catchment area in order to improve the quality of care.

Design - Two study periods of 8 weeks were compared with reference to monitoring sites, i.e. hospital departments and primary health care centres.

Setting - the health care district of Umeå in northern Sweden, with 125 300 inhabitants.

Participants - Patients on oral anticoagulant therapy at the department of Internal Medicine, Umeå University Hospital, in 1987 (n=243) were compared with all patients treated in 1990 at health centres (n=175) and at the department of Internal Medicine (n=290) in the Umeä district.

Main outcome measures - the prevalence of treatment failures and complications was calculated per patient year, as well as the relative frequencies of patients within treatment recommendations.

Results - 80-83% of the patients were within treatment recommendations. Treatment failures were 3.6% of hospital patients, and 2.6% of primary care patients. Corresponding figures for bleeding complications were 8.9% and 5.1%, respectively. the differences are partly explained by differences in the studied groups, e.g. age, indications for treatment, and concomitant diseases.     

The profiles of health care utilization among a non-depressed population and patients with depressive symptoms with and without clinical depression

Abstract

Objective: To examine health service (HS) utilization profiles among a non-depressive population and patients with depressive symptoms (DS) with and without clinical depression.

Design, subjects and setting: The study population was based on primary care patients with DS scoring ≥10 in the 21-item Beck Depression Inventory (BDI) and who were at least 35 years old and had been referred to depression nurse case managers (n?=?705). Their psychiatric diagnosis was confirmed with the Mini-International Neuropsychiatric Interview (M.I.N.I.). Of these patients, 447 had clinical depression. The number of patients with DS without clinical depression was 258. The control group consisted of a random sample of 414 residents with a BDI score < 10. Use of HS (visits and phone calls to a doctor and a nurse) was based on patient records.

Main outcome measures: Number of visits and calls to physicians and nurses.

Results: Patients with DS regardless of their depression diagnosis used primary health care (PHC) services three times more than the controls (p?<?0.001). In the secondary care, the differences were smaller but significant. Of the controls, 70% had 0–4 HS contacts per year whereas a majority of the patients having DS had more than 5 contacts per year. The number of contacts correlated with the BDI from a score of 0 to 10 but not as clearly in the higher scores.

Conclusion: Depressive symptoms, both with or without clinical depression, are associated with increased HS use, especially in PHC. This study suggests that even mild depressive symptoms are associated with an increased use of HS.

• KEY POINTS

• We analyzed the health service (HS) use among primary health care patients screened for depression and non-depressive population.

• Screen positive patients without clinical depression used as much HS as those having clinical depression.

• Regardless of depression diagnosis, screen positive patients visited a GP and nurse three times more often than the control population.

• In the screen negative control population, milder depressive symptoms were correlated with the use of HS.

• Primary health care was responsible for most of the HS use among patients having depressive symptoms.

     

The quality of GP consultation in two different salary systems A Finnish experience

Objective – To compare the quality of consultations between two Finnish employment contract systems: the capitation-based contract (CB) and the time-based contract (TB).

Design – Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs).

Setting and subjects – 81 GPs with their patients from four health care centres in Finland, 2191 encounters.

Main outcome measures – Both patients’ and GPs’ opinions on the role of personal doctor, medico-professional quality, quality of communication, consultation conditions, economic quality (= number of examinations and treatments), and duration of consultation.

Results – Patients were more satisfied than the doctors with the quality of consultations. We found no differences between the groups in the patients’ opinions on the quality. The GPs in the CB group rated their work quality higher than the GPs in the TB group. The patients’ and the GPs’ understanding of the GP as a personal doctor varied so that the patients considered their GP as their personal doctor more often than the GPs in question.

Conclusions – The GPs with a capitation-based contract evaluated the quality of their work higher than other GPs. Patient satisfaction was not dependent on the GP's contract.     

Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Unmet needs and health care utilization in young adults with cerebral palsy

Purpose. To gain insight into the unmet needs and utilization of health care of young adults with cerebral palsy (CP) and to explore relations between unmet needs, health care utilization and subject characteristics.

Method. A cross-sectional study was performed in 29 young adults with CP without severe learning disabilities (IQ > 70). Subject characteristics such as age, gender, limb distribution, level of gross motor functioning, level of education and perceived participation and autonomy were measured. Outcome measures were the Southampton Needs Assessment Questionnaire, Impact on Participation and Autonomy and a questionnaire on health care utilization.

Results. Young adults with CP reported unmet needs mostly on information (79%), mobility (66%) and health care (66%). About half of the participants visited a rehabilitation physician (52%) or a physical therapist (55%) in the past year. Participants with lower levels of gross motor functioning were found to have more unmet needs and visited various health care professionals more often than young adults with higher levels of gross motor functioning. However, participants with higher levels of gross motor functioning still reported several unmet needs.

Conclusions. Although young adults with CP frequently receive treatment from health care professionals, they indicate unmet needs with respect to several areas such as information on diagnosis, functional mobility and formal health care. In the treatment of young adults with CP, attention should be paid to these aspects.     

Side effects of beta-blocker treatment for hypertension

A three-year training programme was developed and implemented by the Medical Centre of Postgraduate Education in Poland with the aim of improving the knowledge and skills of primary health care physicians working in the State Health Services' community centres. The programme creates several learning and self-assessment opportunities with the general principle of not distracting a doctor from his daily duties in a community health centre for more than one day a month.

Preliminary assessment of the programme revealed its positive impact on both the health services system and primary health care physicians themselves. It increased health authorities' activity in creating new learning opportunities and doctors' motivation to learn. Self-assessment made by the first group of traineses who completed the three-year programme (results obtained by means of a questionnaire) revealed substantial increase in professional competence resulting from the participation in the programme.     

Early Rehabilitation at Home of Elderly Patients with Hip Fractures and Consumption of Resources in Primary Care

From 1976 onwards an active rehabilitation programme has been applied to elderly patients with fresh hip fractures at the Department of Orthopaedics in Lund in Southern Sweden. This involves early mobilisation in the hospital (internal fixation and immediate weight-bearing) and at home, rehabilitation in cooperation with primary health care personnel from the time of the patient's admission.

The purposes of this investigation were to evaluate the effect of this programme in primary care and to assess the consumption of resources for rehabilitation at home of patients with cervical or trochanteric hip fractures.

One hundred of 161 consecutive patients returned home directly on discharge from the hospital and were followed up until four months after the fracture by the home care unit (a primary health care centre). Most patients regained their previous functions within four months of their fractures. Patients with cervical fractures consumed less resources for rehabilitation than patients with trochanteric fractures. The total cost per patient was ten times higher for care at a convalescent-home than for rehabilitation at home through primary care.

Early at home rehalibitation of elderly patients with hip fractures gives good results at a minimal cost and is thus of advantage both to the patient and to the community.     

Disentangling the effects of disability and age on health service utilisation

Purpose.?This article examines two competing hypotheses for the impact of disability and age on health service utilisation in Canada: the double jeopardy and age-as-leveller hypotheses.

Method.?The study uses a retrospective cohort design to examine the effect of age and disability on four aspects of health service utilisation: family doctor, medical specialist, hospital and homecare. The cohort was assembled from the longitudinal component of the National Population Health Survey. The effective sample size for this analysis was 1629.

Results.?This study showed that disability is a stronger predictor of doctor and hospital utilisation than age. No significant relationship was found between age and specialist use, and there were only small to moderate increases in the use of family doctors and hospitals with each 5-year increment of age over 65. There is a strong association between the use of home care and both age and disability. Results support the age-as-leveller hypothesis, in that negative interaction effects were found between age and disability for use of both family physicians and medical specialists. In other words, age and disability together have an effect that is less than would be expected, given the main effects of each.

Conclusion.?The results of this study support the importance of disability as an indicator of health service utilisation. Rehabilitation practitioners are encouraged to continue to sensitise other members of the health care team to the importance of disability as a way of understanding health and health service use.     

Use of health care among adults with chronic and complex physical disabilities of childhood

Purpose.?The purpose of this study was to explore the patterns of health services utilization among adults with chronic and complex physical disabilities of childhood, specifically cerebral palsy, spina bifida, and acquired brain injuries.

Methods.?A cohort of 345 young adults who had graduated from the Bloorview MacMillan Children's Centre was identified. Their health care records were extracted from Ontario Health Insurance Plan (OHIP) and Canadian Institute for Health Information (CIHI) databases, for a four-year period. These data were analysed to estimate the frequency of out-patient physician visits and admissions to hospital.

Results.?The mean age of the sample was 21.9 years (range 19.0–26.9 years). The results show that 95% of the sample visited a physician at least once per year, and 24% had a primary care physician. On average, these adults visited physicians 11.5 times per year (approximately once per month) and were admitted to hospital once every 6.8 years.

Conclusions.?These results suggest that adults with complex physical disabling conditions from childhood have ongoing health issues that require frequent service. Their admission rate is 9.0 times that of the general population, and few have a primary care physician. A new model of service may be necessary for this high-needs group.     

Secondary health conditions in persons with a spinal cord injury for at least 10 years: design of a comprehensive long-term cross-sectional study

Purpose: To describe the prevalence of secondary health conditions (SHCs) (urinary tract and bowel problems, pressure ulcers, spasticity, musculoskeletal and neuropathic pain, sexual dysfunction, respiratory and cardiovascular disorders) in persons with long-term spinal cord injury (SCI), and to explore the impact of SHCs on fitness, active lifestyle, participation and well-being. Methods: A time since injury (TSI)-stratified cross-sectional study among 300 persons between 28- and 65-year-old with a SCI for at least 10 years. Strata of TSI are 10–19, 20–29, and 30 or more years. All eight Dutch rehabilitation centres with a SCI unit will participate. Participants will be invited for a 1-day visit to the rehabilitation centre for an aftercare check-up by the local SCI rehabilitation physician (neurological impairment, SHCs and management), physical tests by a trained research assistant (lung function, wheelchair skills, physical capacity), and they will be asked to complete a self-report questionnaire in advance. Results: Not applicable. Conclusion: This study will provide knowledge on the health status and functioning of persons aging with SCI living in the Netherlands. This knowledge will help us to develop predictive models for the occurrence of SHCs and to formulate guidelines to improve health care for persons with long-term SCI.

Implications for Rehabilitation

• Persons with long-term spinal cord injury may be susceptible to many types of secondary health conditions (i.e. pressure ulcers, urinary tract infections, pain and spasticity).

• Coordinated long-term health care is required for this population but this is currently not operational in all specialized rehabilitation centres in the Netherlands.

• This study aims to develop predictive models for the occurrence of secondary health conditions and to develop guidelines to improve long-term health care for persons living with a spinal cord injury in the Netherlands.

     

2012 and 2013 Peer Review Panel

The aim of the study to examine a six-year development of the panorama of contacts and diagnoses at Södra Sandby Health Centre, where care teams had been introduced, and then to compare this development with that of the rest of the Dalby primary care district, where there were no care teams.

In Södra Sandby the number of contacts with general practititioners (GPs) increased between 1984 and 1989 by 8% more than expected from the increase in staff, while the number of contacts with district care (district nurses and assistant nurse) increased by 62% more than expected. The corresponding figures for Dalby were 1% and 34%, respectively. The total proportion of the population visiting GPs in Södra Sandby during 1989 was 54%, and in Dalby 58%. The corresponding figure for district care in Södra Sandby was 40%. The proportion of contacts for which no appointment was made in advance decreased in Södra Sandby from 45% in 1984 to 22% in 1989. The corresponding figures for Dalby were 61% and 64%.

This study did not find any verification for the fear that the organization of care teams would lead to a reduction in the number of contacts, e.g. on account of the frequency of meetings and conferences. The nurses seemed to retain their independent role, with the population contacting them in their surgeries or the nurses visiting them at home.     

Report from University of Birmingham

Objective To evaluate prerequisites, practicalities, attitudes and limitations related to the collection of structured clinical data in everyday general practice for use in the future establishment of a national registration network.

Design Prospective study.

Setting Primary health care centres in south-western Sweden.

Subjects Fourteen participating general practitioners in five primary health care centres.

Main outcome measures Feasibility and workload involved in structured data entry and in the retrieval of data from different record systems. The accuracy of clinical data in terms of clinical variables, correctness and representativeness.

Results All four record systems could deliver basic data on the patient population. One centre had to be excluded from further data retrieval because of limitations in the data retrieval export format. Collecting data in everyday practice was feasible with acceptable data accuracy and moderate workload.

Conclusion It was feasible to collect, retrieve and store structured clinical data with respect to accuracy and extra workload. Interest in a national registration network and an increasing demand for information about primary health care in order to optimise clinical practices and support research, creates prerequisites for establishing a valid and reliable database. However, developmental work focusing on classification limitations, coding tools and routines for data retrieval is necessary.     

Reasons for attending a general emergency outpatient clinic versus a regular general practitioner – a survey among immigrant and native walk-in patients in Oslo,Norway

Objective: To explore reasons for attending a general emergency outpatient clinic versus a regular general practitioner (RGP).

Design: Cross-sectional study using a multilingual anonymous questionnaire.

Setting: Native and immigrant walk-in patients attending a general emergency outpatient clinic in Oslo (Monday–Friday, 08:00–23:00) during 2 weeks in September 2009.

Subjects: We included 1022 walk-in patients: 565 native Norwegians (55%) and 457 immigrants (45%).

Main outcome measures: Patients’ reasons for attending an emergency outpatient clinic versus their RGP.

Results: Among patients reporting an RGP affiliation, 49% tried to contact their RGP before this emergency encounter: 44% of native Norwegian and 58% of immigrant respondents. Immigrants from Africa [odds ratio (OR)?=?2.55 (95% confidence interval [CI]: 1.46–4.46)] and Asia [OR?=?2.32 (95% CI: 1.42–3.78)] were more likely to contact their RGP before attending the general emergency outpatient clinic compared with native Norwegians. The most frequent reason for attending the emergency clinic was difficulty making an immediate appointment with their RGP. A frequent reason for not contacting an RGP was lack of access: 21% of the native Norwegians versus 4% of the immigrants claimed their RGP was in another district/municipality, and 31% of the immigrants reported a lack of affiliation with the RGP scheme.

Conclusions and implications: Access to primary care provided by an RGP affects patients’ use of emergency health care services. To facilitate continuity of health care, policymakers should emphasize initiatives to improve access to primary health care services.

• KEY POINTS

• Access to immediate primary health care provided by a regular general practitioner (RGP) can reduce patients’ use of emergency health care services.

• The main reason for attending a general emergency outpatient clinic was difficulty obtaining an immediate appointment with an RGP.

• A frequent reason for native Norwegians attending a general emergency outpatient clinic during the daytime is having an RGP outside Oslo.

• Lack of affiliation with the RGP scheme is a frequent reason for attending a general emergency outpatient clinic among immigrants.

     

Cancer patients’ use of primary care out-of-hours services: a cross-sectional study in Norway

Objective: To investigate how cancer patients in Norway use primary care out-of-hours (OOH) services and describe different contact types and procedures.

Design: A retrospective cross-sectional registry study using a billing registry data source.

Setting: Norwegian primary care OOH services in 2014.

Subjects: All patients’ contacts in OOH services in 2014. Cancer patients were identified by ICPC-2 diagnosis.

Main outcome measures: Frequency of cancer patients’ contacts with OOH services, contact types, diagnoses, procedures, and socio-demographic characteristics.

Results: In total, 5752 cancer patients had 20,220 contacts (1% of all) in OOH services. Half of the contacts were cancer related. Cancer in the digestive (22.9%) and respiratory (18.0%) systems were most frequent; and infection/fever (21.8%) and pain (13.6%) most frequent additional diagnoses. A total of 4170 patients had at least one cancer-related direct contact; of these, 64.5% had only one contact during the year. Cancer patients had more home visits and more physicians’ contact with municipal nursing services than other patients, but fewer consultations (p?p?Conclusion: There was no indication of overuse of OOH services by cancer patients in Norway, which could indicate good quality of cancer care in general.

• KEY POINTS

• Many are concerned about unnecessary use of emergency medical services for non-urgent conditions.

• ??There was no indication of overuse of out-of-hours services by cancer patients in Norway.

• ??Cancer patients had relatively more home visits, physician’s contact with the municipal nursing service, and weekend contacts than other patients.

• ??Cancer patients in the least central municipalities had relatively more contacts with out-of-hours services than those in more central municipalities.

     

Advance Care Planning in Community-Dwelling Patients With Dementia

Context

Little is known about advance care planning (ACP) among community-dwelling patients with dementia.

Coordinate My Care: A clinical approach underpinned by an electronic solution

Abstract

Coordinate My Care (CMC) is a clinical approach underpinned by an electronic solution. It puts the patient at the centre. All clinical care plans, advance care plans and patients wishes are central to a CMC record. The record can be accessed 24/7 by all legitimate health and social professionals caring for an individual patient, including the out of hours general practitioner (GP) services, 111 and the London Ambulance Service. Two-thirds of each week is out of hours; CMC provides an up-to-date record for patients at all times. The key to CMC is planning. Planning care avoids crises; avoiding crises results in fewer unnecessary hospital admissions. CMC enables more patients (82.4%) to die in their preferred place (home, care home, hospice) and fewer patients to die in hospital. CMC improves access of care to patients care homes and to patients with non-malignant diseases (55%).