Violence towards personnel in out-of-hours primary care: a cross-sectional study

Objective

To investigate (1) the prevalence of occupational violence in out-of-hours (OOH) primary care, (2) the perceived cause of violence, and (3) the associations between occupation, gender, age, years of work, and occupational violence.

Design

A cross-sectional study using a self-administered postal questionnaire.

Setting

Twenty Norwegian OOH primary care centres.

Subjects

Physicians, nurses, and others with patient contact at OOH primary care centres, 536 responders (75% response rate).

Main outcome measures

Verbal abuse, threats, physical abuse, sexual harassment.

Results

In total, 78% had been verbally abused, 44% had been exposed to threats, 13% physically abused, and 9% sexually harassed during the last 12 months. Significantly more nurses were associated with verbal abuse (OR 3.85, 95% confidence interval 2.17–6.67) after adjusting for gender, age, and years in OOH primary care. Males had a higher risk for physical abuse (OR 2.36, CI 1.11–5.05) and higher age was associated with lower risk for sexual harassment (OR 0.28, CI 0.14–0.59), when adjusted for background variables. Drug influence and mental illness were the most frequently perceived causes for the last occurring episode of physical abuse, threats, and verbal abuse.

Conclusion

This first study on occupational violence in Norwegian OOH primary care found that a substantial number of health care workers experience occupational violence from patients or visitors. The employer should take action to prevent occupational violence in OOH primary care.Key Words: Cross-sectional studies, general practice, nurses, out-of-hours, physicians, prevalence, violenceThis study describes the prevalence of occupational violence among health workers in Norwegian out-of-hours primary care.

• One in three has been exposed to physical abuse during their working career in out-of-hours primary care.
• Nurses experience more verbal abuse than the other occupational groups.
• The perceived main causes of occupational violence are drug influence and mental illness.

     

Use of laboratory tests in out-of-hours services in Norway

Objective

To investigate the use of laboratory tests and which factors influence the use in Norwegian out-of-hours (OOH) services.

Design

Cross-sectional observational study.

Setting

Out-of-hours services in Norway.

Subjects

All electronic reimbursement claims from doctors at OOH services in Norway in 2007.

Main outcome measures

Number of contacts and laboratory tests in relation to patients’ and doctors’ characteristics.

Results

1 323 281 consultations and home visits were reported. Laboratory tests were used in 31% of the contacts. C-reactive protein (CRP) was the most common test (27% of all contacts), especially in respiratory illness (55%) and infants (44%). Electrocardiogram and rapid strep A test were used in 4% of the contacts. Young doctors, female doctors, and doctors in central areas used laboratory tests more often.

Conclusion

CRP is extensively used in OOH services, especially by young and inexperienced doctors, and in central areas. Further investigations are required to see if this extensive use of CRP is of importance for correct diagnosis and treatment.Key Words: Clinical chemistry tests, CRP, diagnostic tests, emergency medical services, primary health careA few point-of-care laboratory tests are available for diagnostic use in out-of-hours services in Norway.

• A laboratory test was taken in 31% of all consultations/home calls.
• C-reactive protein (CRP) was the dominating test (27% of all contacts), and the rate was especially high in small children.
• Test use was most frequent in out-of-hours services in central areas and by younger doctors.

     

Patient satisfaction with out-of-hours GP cooperatives: A longitudinal study

Objective

For over a decade, out-of-hours primary care in the Netherlands has been provided by general practitioner (GP) cooperatives. In the past years, quality improvements have been made and patients have become acquainted with the service. This may have increased patient satisfaction. The objective of this study was to examine changes in patient satisfaction with GP cooperatives over time.

Design

Longitudinal observational study. A validated patient satisfaction questionnaire was distributed in 2003–2004 (T1) and 2007–2008 (T2). Items were rated on a scale from 0 to 10 (1 = very bad; 10 = excellent).

Setting

Eight GP cooperatives in the Netherlands.

Subjects

Stratified sample of 9600 patients. Response was 55% at T1 (n = 2634) and 51% at T2 (n = 2462).

Main outcome measures

Expectations met; satisfaction with triage nurses, GPs, and organization.

Results

For most patients the care received at the GP cooperative met their expectations (T1: 86.1% and T2: 88.4%). Patients were satisfied with the triage nurses (overall grade T1: 7.73 and T2: 7.99), GPs (T1: 8.04 and T2: 8.25), and organization (overall grade T1: 7.60 and T2: 7.78). Satisfaction with triage nurses showed the largest increase over time. The quality and effectiveness of advice or treatment were given relatively low grades. Of all organizational aspects, the lowest grades were given for waiting times and information about the cooperative.

Conclusion

In general, patients were initially satisfied with GP cooperatives and satisfaction had even increased four years later. However, there is room for improvement in the content of the advice, waiting times, and information supply. More research is needed into satisfaction of specific patient groups.Key Words: After hours, general practice, GP cooperatives, patient satisfaction, primary care, survey, The NetherlandsPatient experiences are an important element of quality of care. This study showed that a few years after the onset of GP cooperatives in the Netherlands, patients were satisfied with this out-of-hours primary care service. On most aspects, satisfaction had even increased four years later. However, there is still room for improvement in the content of the advice, waiting times, and information supply.     

Contacts related to mental illness and substance abuse in primary health care: A cross-sectional study comparing patients' use of daytime versus out-of-hours primary care in Norway

Objective

To investigate prevalence, diagnostic patterns, and parallel use of daytime versus out-of-hours primary health care in a defined population (n = 23,607) in relation to mental illness including substance misuse.

Design

Cross-sectional observational study.

Setting

A Norwegian rural general practice cooperative providing out-of-hours care (i.e. casualty clinic) and regular general practitioners’ daytime practices (i.e. rGP surgeries) in the same catchment area.

Subjects

Patients seeking medical care during daytime and out-of-hours in 2006.

Main outcome measures

Patients’ diagnoses, age, gender, time of contact, and parallel use of the two services.

Results

Diagnoses related to mental illness were given in 2.2% (n = 265) of encounters at the casualty clinic and in 8.9% (n = 5799) of encounters at rGP surgeries. Proportions of diagnoses related to suicidal behaviour, substance misuse, or psychosis were twice as large at the casualty clinic than at rGP surgeries. More visits to the casualty clinic occurred in months with fewer visits to rGP surgeries. Most patients with a diagnosis related to mental illness at the casualty clinic had been in contact with their rGP during the study period.

Conclusion

Psychiatric illness and substance misuse have lower presentation rates at casualty clinics than at rGP surgeries. The distribution of psychiatric diagnoses differs between the services, and more serious mental illness is presented out-of-hours. The casualty clinic seems to be an important complement to other medical services for some patients with recognized mental problems.Key Words: After-hours care, emergency medical services, family practice, physician''s practice patterns, primary health care, psychiatryMost mentally ill patients in Norway are dealt with by the primary health care system, and out-of-hours GP services are the main source of acute referrals to psychiatric wards. Differences between daytime and out-of-hours services regarding relative prevalence, diagnostic challenges, and parallel use have previously been unknown.

• Prevalence of diagnoses related to mental illness is lower at out-of-hours services compared with daytime services. However, suicidal behaviour, substance misuse, and psychosis are more prevalent out-of-hours than during the daytime.
• Use of out-of-hours services increases in periods with low use of daytime services.
• Most patients with diagnoses related to mental illness out-of-hours had also seen their regular general practitioner during the study period.

Norway has a two-tier public health care system where regular general practitioners (rGPs) serve as gatekeepers for all specialized health services including psychiatric health care [1,2]. Most patients with mental illness are therefore dealt with by the primary health care system, with relatively few patients referred to psychiatrists [3,4].Local municipalities (Norwegian kommuner) are responsible for providing all primary health care, including access to an rGP and 24-hour access to emergency health care [5,6]. Although optional, almost all Norwegians are listed with an rGP in their residing municipality. The rGPs provide emergency care to their listed patients during office hours. Out-of-hours, most municipalities organize the emergency care with one or more GPs on call, usually based in a casualty clinic. Depending on the size of the municipality and the population served, the casualty clinic might be cooperatively shared between several municipalities [1]. Henceforth casualty clinic is used as a general term for out-of-hours services, and rGP surgeries refer to rGPs’ work during normal office hours. At a national level, approximately 66% of inhabitants annually have at least one appointment with their rGP and 16% contact the casualty clinics [7].International studies indicate that psychiatric patients are frequent users of emergency medical health services [12–14]. In Norway, however, diagnoses related to mental illness are given in only 2–5% of patient contacts with casualty clinics [7,9,10,15], while mental illness accounts for 5–12% of consultations at rGP surgeries [7–11]. Nevertheless, casualty clinics are the major source of acute referrals to psychiatric wards [16]. This raises the possibility that patients’ use of the two primary health care services may differ, and that casualty clinics mainly deal with more severe mental illness.In this study we compared a defined population''s use of daytime rGP appointments versus their use of the out-of-hours casualty clinic in relation to mental illness. Main measures were relative prevalence and diagnostic differences. We also studied patients’ parallel use of these two services.     

The Patient Experiences Questionnaire for Out-of-Hours Care (PEQ-OHC): data quality,reliability, and validity

Objective

To develop and evaluate the Patient Experiences Questionnaire for Out-of-Hours Care (PEQ-OHC) in Norway.

Design

Questionnaire development was based on a systematic literature review of existing questionnaires, interviews with users, and expert group consultation. Questionnaire testing followed a postal survey of users who had attended out-of-hours centres in the North, West, and South of Norway.

Setting

Primary care out-of-hours services.

Subjects

The questionnaire was pre-tested with 13 users and was then mailed to 542 users who had had telephone contact and/or had a consultation with one of three out-of-hours centres.

Main outcome measures

Data quality, internal consistency, reliability, and construct validity.

Results

The questionnaire was considered to have good content validity by the expert group. There were 225 (41.51%) respondents to the postal questionnaire. Levels of missing data at the item and scale level were acceptable. Principal component analysis supported the four scales of user experiences relating to telephone contact, doctor services, nursing services, and organization. Item-total correlations were all above 0.5 and Cronbach''s alpha was above 0.80 for all scales. Statistically significant associations based on explicit hypotheses were evidence for the construct validity of the PEQ-OHC.

Conclusion

The development of the PEQ-OHC followed a rigorous process based on a systematic review, interviews with users, and an expert group which lend the questionnaire content validity. The PEQ-OHC has evidence for data quality, internal consistency, reliability, and construct validity.Key Words: Family practice, out-of-hours, patient satisfaction, questionnaire, reliability, survey, validityQuestionnaires are increasingly used for assessing patient experiences of out-of-hours care.

• Existing questionnaires have limitations relating to data quality, reliability, and validity.
• The PEQ-OHC has undergone a rigorous process of development following a systematic review and interviews with patients.
• The PEQ-OHC has good evidence for data quality, reliability, and validity.

There have been considerable changes in the organization of out-of-hours primary care in Europe [1–3]. The care setting has moved away from the home to the primary care centre and telephone consultations, which has followed the growth of GP cooperatives and deputizing services [4]. However, the evaluation of developments within out-of-hours care has been limited in scope focusing on the process of care [5], which may stem from the lack of availability of questionnaires that are based on the views of users concerning their experiences or satisfaction with services [4,6,7]. There are several questionnaires that assess user experiences and satisfaction with primary healthcare more generally [8–10] but there is a lack of questionnaires specific to out-of-hours care that have sufficient evidence for data quality, reliability, and validity [7].According to a systematic review there was just one questionnaire relating to user satisfaction with out-of-hours care that was published before 2005 [7]. The review identified four questionnaires, two from the Netherlands and two from the UK, concluding that all four had limitations in terms of their development and evaluation. The development of the questions within two questionnaires did not include users, which has implications for content validity [8]. Two questionnaires had poor reliability estimates and there was evidence for item redundancy within a third. Evidence for the validity of all four questionnaires was considered to be limited [7].It is important that these shortcomings are addressed through further development and evaluative work to ensure that such questionnaires meet the necessary criteria for use within evaluative studies and for quality improvement initiatives [11]. Questionnaires that are valid and reliable and based on the views of users [8] are also required for national surveys of user views of out-of-hours care such as that undertaken within the Netherlands [4] and for providers wishing to monitor user experiences and satisfaction as has been recommended in the UK [12].Norway has a programme of national surveys that measure user experiences of care [13–16]. The survey results are designed to inform patient choice and healthcare quality improvement. The survey questionnaires are based on the views of users and experts and have good evidence for data quality, reliability, and validity [13–16]. A systematic review was undertaken that was designed to inform a survey of users of out-of-hours care in Norway [7]. The work that follows describes the development of the Patient Experiences Questionnaire for Out of Hours Care (PEQ-OHC) and testing for data quality, internal consistency, reliability, and validity. This Norwegian questionnaire is available for forward–backwards translation for countries with a similar provision of out-of-hours care but the relevance of the content of the PEQ-OHC must first be considered.     

GPs' use of defibrillators and the national radio network in emergency primary healthcare in Norway

Objective

To study the geographic size of out-of-hours districts, the availability of defibrillators and use of the national radio network in Norway.

Design

Survey.

Setting

The emergency primary healthcare system in Norway.

Subjects

A total of 282 host municipalities responsible for 260 out-of-hours districts.

Main outcome measures

Size of out-of-hours districts, use of national radio network and access to a defibrillator in emergency situations.

Results

The out-of-hours districts have a wide range of areas, which gives a large variation in driving time for doctors on call. The median longest transport time for doctors in Norway is 45 minutes. In 46% of out-of-hours districts doctors bring their own defibrillator on emergency callouts. Doctors always use the national radio network in 52% of out-of-hours districts. Use of the radio network and access to a defibrillator are significantly greater in out-of-hours districts with a host municipality of fewer then 5000 inhabitants compared with host municipalities of more than 20 000 inhabitants.

Conclusion

In half of out-of-hours districts doctors on call always use the national radio network. Doctors in out-of-hours districts with a host municipality of fewer than 5000 inhabitants are in a better state of readiness to attend an emergency, compared with doctors working in larger host municipalities.     

The feasibility of antibiotic dosing four times per day: a prospective observational study in primary health care

Objective

To investigate whether the increase in the number of doses of penicillin V from three times daily to four times daily for common infections, as recommended in the new Norwegian guidelines for antibiotic treatment in primary health care, would lead to reduced patient compliance.

Design

Prospective observational study.

Setting and subjects

Six general practitioners included all patients who were prescribed systemic antibiotic treatment regardless of indication during a 10-month period. A total of 270 patients provided data for the study.

Methods

Telephone interview focusing on omitted antibiotic doses.

Results

Some 17% of patients had poor compliance, defined as failing to take 5% or more of total antibiotic doses. Neither level of poor compliance nor number of omitted doses differed significantly when the number of daily doses increased from three to four. There were significantly fewer omitted doses in the group given two doses per day when compared with three doses (p = 0.04) and four doses per day (p = 0.01).

Conclusion

We found no difference in compliance or omitted doses between antibiotic regimens of three and four doses per day. The new Norwegian guidelines for antibiotic treatment in primary health care appear feasible with regard to patient compliance.Key Words: Antibiotics, guidelines, Norway, patient non-compliance, primary care, treatmentCompliance with antibiotic treatment has been shown to decrease with increasing dose frequency. New Norwegian guidelines for antibiotic treatment in primary health care recommend penicillin V dosing four times per day as compared with three times per day in earlier recommendations.

• An overall good compliance with treatment was found, even with regimens of four doses per day.
• There was no significant difference in compliance when comparing four antibiotic doses per day with three doses per day.
• The new Norwegian guidelines for antibiotic treatment in primary health care appear feasible in clinical practice.

     

The medico-professional quality of GP consultations assessed by analysing patient records

Objective

To assess the medico-professional quality of consultations by analysing textual data from patient records.

Design

Qualitative analyse of textual data.

Setting

Four primary health care centres using electronic patient records (EPR) in Finland.

Subjects

EPR and paired questionnaires of 175 consultations filled in by GPs and their patients independently.

Main outcome measures

Medico-professional quality of consultations, quality of care of acute respiratory infections, and hypertension.

Results

The medico-professional quality of the consultations was quite good. However, 9% of the records could not been assessed at all because of missing or poor documentation and 9% were assessed as poor. The treatment of acute respiratory infections and hypertension is not in line with current care guidelines. Smoking habits or other health behaviour or lifestyle factors were seldom recorded.

Conclusions

The medico-professional quality of the consultation was quite good. Quality improvement is needed in the treatment of acute respiratory infections and hypertension. User-friendly EPR systems would improve the content of patient records.Key Words: Acute respiratory infections, consultation, electronic patient records, general practice, hypertension, quality of health careMost studies on EPR have investigated structured rather than textual data of patient records.

• Textual assessment of patient records implies that the medico-professional quality of consultations is quite good.
• Textual assessment of patient records shows that quality improvement is needed in the treatment of acute respiratory infections and hypertension.
• User-friendly EPR systems improve the content of patient records.

     

Panic disorder in primary care: Comorbid psychiatric disorders and their persistence

Objective

Although 70–80% of panic disorder patients use primary care to obtain mental health services, relatively few studies have examined panic patients in this setting. This study aimed to examine both the lifetime and current comorbid psychiatric disorders associated with panic disorder in primary care, the duration and severity of the disorder, and the sociodemographic factors associated with it.

Design

Patients were screened for panic disorder. Panic disorder and the comorbid disorders were determined using the Structured Clinical Interview for DSM-IV Axis I and II.

Setting

Eight different health care centers in primary care in the city of Espoo.

Subjects

Finnish-speaking, between 18 and 65 years of age.

Main outcome measures

Comorbid psychiatric disorders, the duration and severity of the disorder, and the sociodemographic factors.

Results

A sample of 49 panic disorder patients and 44 patients with no current psychiatric diagnosis were identified; 98% of panic disorder patients had at least one comorbid lifetime DSM-IV Axis I disorder. Major depressive disorder and other anxiety disorders were most common comorbid disorders. Lifetime alcohol use disorders also showed marked frequency. Interestingly, the remission rates of alcohol use disorders were notable. The panic symptoms appeared to persist for years. Panic disorder was associated with low education and relatively low probability of working full time.

Conclusions

Also in primary care panic disorder is comorbid, chronic, and disabling. It is important to recognize the comorbid disorders. High remission rates of comorbid alcohol use disorders encourage active treatment of patients also suffering from these disorders.Key Words: Comorbid disorders, Finland, general practice, panic disorder, primary careThere are only a few studies considering the comorbid psychiatric disorders associated with panic disorder in primary care and no earlier study had examined the prevalence of all other psychiatric disorders, both lifetime and current, using a structured diagnostic interview method.

• In this study 98% of panic disorder patients had at least one comorbid lifetime psychiatric disorder.
• Major depressive disorder, other anxiety disorders, and alcohol use disorders were the most common comorbid disorders.
• The panic symptoms appeared to persist for years.

     

Who is the key worker in palliative home care?

Objective

Palliative home care involves coordination of care between the professionals involved. The NICE guideline on supportive and palliative care (UK) recommends that teams, regardless of their base, should promote continuity for patients. This may involve nomination of a coordinating “key worker”. This study aimed to explore who acts as key worker and who ought to take on this role in the views of patients, relatives, and primary care professionals. Furthermore, it aimed to explore the level of agreement on this issue between study participants.

Design

Interview and questionnaire study.

Setting

Former County of Aarhus, Denmark (2008–2009).

Subjects

Ninety-six terminally ill cancer patients, their relatives, general practitioners (GPs), and community nurses (CNs).

Main outcome measures

Actual key worker as valued by patients, relatives, and primary care professionals; ideal key worker as valued by patients and relatives.

Results

Patients, relatives, GPs, and CNs most often saw themselves as having been the key worker. When asked about the ideal key worker, most patients (29%; 95%CI: 18;42) and relatives (32%; 95%CI: 22;45) pointed to the GP. Using patients’ views as reference, we found very limited agreement with relatives (47.7%; k = 0.05), with GPs (30.4%; k = 0.01) and with CNs (25.0%; k = 0.04). Agreement between patients and relatives on the identity of the ideal key worker was of a similar dimension (29.6%; k = 0.11).

Conclusion

Poor agreement between patients, relatives, and professionals on actual and ideal key worker emphasizes the need for matching expectations and clear communication about task distribution in palliative home care.Key Words: Denmark, organisation and administration, palliative care, patient care, primary health careCoordination of care is of great importance to families receiving palliative home care. The GP is often considered the obvious coordinating key worker in palliative care pathways.

• This study demonstrates a marked disagreement between patients, relatives, and primary care professionals on who acts as the key worker.
• Most patients and relatives considered themselves to be the actual key worker but the GP to be the ideal key worker.
• Clear communication among families and professionals on expectations and responsibilities can improve care and collaboration in primary palliative care.

     

Factors associated with undiagnosed obstructive sleep apnoea in hypertensive primary care patients

Objective

In hypertensive primary care patients below 65 years of age, (i) to describe the occurrence of undiagnosed obstructive sleep apnoea (OSA), and (ii) to identify the determinants of moderate/severe OSA.

Design

Cross-sectional.

Setting

Four primary care health centres in Sweden.

Patients

411 consecutive patients (52% women), mean age 57.9 years (SD 5.9 years), with diagnosed and treated hypertension (BP >140/90).

Main outcome measures

Occurrence of OSA as measured by the apnoea hypopnoea index (AHI).

Results

Mild (AHI 5–14.9/h) and moderate/severe (AHI > 15/h) OSA were seen among 29% and 30% of the patients, respectively. Comparing those without OSA with those with mild or moderate/severe OSA, no differences were found in blood pressure, pharmacological treatment (anti-hypertensive, anti-depressive, and hypnotics), sleep, insomnia symptoms, daytime sleepiness, or depressive symptoms. Obesity (BMI > 30 kg/m2) was seen in 30% and 68% of the patients with mild and moderate/severe OSA, respectively. Male gender, BMI > 30 kg/m2, snoring, witnessed apnoeas, and sleep duration >8 hours were determinants of obstructive sleep apnoea.

Conclusion

Previously undiagnosed OSA is common among patients with hypertension in primary care. Obesity, snoring, witnessed apnoeas, long sleep duration, and male gender were the best predictors of OSA, even in the absence of daytime sleepiness and depressive symptoms.Key Words: Depression, hypertension, obstructive sleep apnoea, sleep, sleep disordered breathing, snoringCurrent awareness:

• Obstructive sleep apnoea has been linked to hypertension in sleep clinic populations, but there is a lack of knowledge regarding the occurrence in Swedish hypertensive primary care patients.

Main statements:

• Undiagnosed mild and moderate/severe obstructive sleep apnoea was seen among 29% and 30% of patients, respectively.
• Comparing subjects with mild or moderate/severe obstructive sleep apnoea with those without, no differences were found in blood pressure, self-rated sleep duration, insomnia, daytime sleepiness, or depressive symptoms.
• Male gender, BMI > 30 kg/m00B2, snoring, witnessed apnoeas, and sleep duration >8 hours were determinants of moderate/severe obstructive sleep apnoea in hypertensive primary care patients.

     

Reasons for not reporting patient safety incidents in general practice: A qualitative study

Objective

To explore the reasons for not reporting patient safety incidents in general practice.

Design

Qualitative interviews with general practitioners and members of the project group.

Setting

General practice clinics in the Region of Northern Jutland in Denmark.

Subjects

Twelve general practitioners.

Main outcome measures

The experiences and reflections of the involved professionals with regard to system use and non-use.

Results

While most respondents were initially positive towards the idea of reporting and learning from patient safety incidents, they actually reported very few incidents. The major reasons for the low reporting rates are found to be a perceived lack of practical usefulness, issues of time and effort in a busy clinic with competing priorities, and considerations of appropriateness in relation to other professionals.

Conclusion

The results suggest that the visions of formal, comprehensive, and systematic reporting of (and learning from) patient safety incidents will be quite difficult to realize in general practice. Future studies should investigate how various ways of organizing incident reporting at the regional level influence local activities of reporting and learning in general practice.Key Words: Denmark, general practice, incident reporting, interviews, patient safety, qualitative researchPrevious studies have reported positive attitudes to incident reporting among Danish GPs.

• The results suggest, however, that formal reporting of patient safety incidents may be more attractive to GPs as an idea than as an integrated activity in a busy clinic. While most GPs in this study were initially positive towards the idea of reporting, they actually reported very few incidents.
• The reasons for the low reporting rates were found to be a perceived lack of usefulness, issues of time and effort, and considerations of appropriateness.
• Future research should compare how various ways of implementing and organizing incident reporting influence local activities of reporting and learning.

     

Increased registration of hypertension and cancer diagnoses after the introduction of a new reimbursement system

Objective

To investigate the impact on ICD coding behaviour of a new case-mix reimbursement system based on coded patient diagnoses. The main hypothesis was that after the introduction of the new system the coding of chronic diseases like hypertension and cancer would increase and the variance in propensity for coding would decrease on both physician and health care centre (HCC) levels.

Design

Cross-sectional multilevel logistic regression analyses were performed in periods covering the time before and after the introduction of the new reimbursement system.

Setting

Skaraborg primary care, Sweden.

Subjects

All patients (n = 76 546 to 79 826) 50 years of age and older visiting 468 to 627 physicians at the 22 public HCCs in five consecutive time periods of one year each.

Main outcome measures

Registered codes for hypertension and cancer diseases in Skaraborg primary care database (SPCD).

Results

After the introduction of the new reimbursement system the adjusted prevalence of hypertension and cancer in SPCD increased from 17.4% to 32.2% and from 0.79% to 2.32%, respectively, probably partly due to an increased diagnosis coding of indirect patient contacts. The total variance in the propensity for coding declined simultaneously at the physician level for both diagnosis groups.

Conclusions

Changes in the healthcare reimbursement system may directly influence the contents of a research database that retrieves data from clinical practice. This should be taken into account when using such a database for research purposes, and the data should be validated for each diagnosis.Key Words: Electronic health records, general practice, ICD codes, incentive, multilevel analysis, primary health care, reimbursement, SwedenIntroducing a new reimbursement system based on patient diagnoses at all consultations:

• increased registration of diagnoses of chronic diseases like hypertension and cancer;
• decreased the variation in diagnosis coding between physicians;
• seemed to be a powerful intervention for increasing the recording of diagnosis codes.

     

Prevalence of urinary tract infection (UTI) in sequential acutely unwell children presenting in primary care: exploratory study

Background

Due to the non-specific nature of symptoms of UTI in children and low levels of urine sampling, the prevalence of UTI amongst acutely ill children in primary care is unknown.

Objectives

To undertake an exploratory study of acutely ill children consulting in primary care, determine the feasibility of obtaining urine samples, and describe presenting symptoms and signs, and the proportion with UTI.

Design

Exploratory, observational study.

Setting

Four general practices in South Wales.

Subjects

A total of 99 sequential attendees with acute illness aged less than five years.

Main outcome measure

UTI defined by >10⁵ organisms/ml on laboratory culture of urine.

Results

Urine samples were obtained in 75 (76%) children. Three (4%) met microbiological criteria for UTI. GPs indicated they would not normally have obtained urine samples in any of these three children. However, all had received antibiotics for suspected alternative infections.

Conclusion

Urine sample collection is feasible from the majority of acutely ill children in primary care, including infants. Some cases of UTI may be missed if children thought to have an alternative site of infection are excluded from urine sampling. A larger study is needed to more accurately determine the prevalence of UTI in children consulting with acute illness in primary care, and to explore which symptoms and signs might help clinicians effectively target urine sampling.Key Words: Children, diagnosis, prevalence, primary care, urinary tract infectionDiagnosis of UTI in young children is difficult as symptoms are non-specific and urine samples often hard to obtain. The presentation of 99 unwell children in general practice is described.

• Urine samples were obtained in over 75% of cases; 4% of these met microbiological criteria for a UTI.
• Although more robust epidemiological studies are required, GPs should maintain a high index of suspicion of the possibility of UTI and have a low threshold for urine sampling.

Symptoms of UTI in young children tend to be non-specific [1]. If UTI is not suspected or there is difficulty obtaining a sample, the diagnosis will be missed. This is particularly the case in primary care where children frequently consult with non-specific symptoms and where appropriate paediatric equipment is not always available [2].Urine is infrequently sampled from children in primary care [3]. In 2007, the UK National Institute for Clinical Excellence (NICE) issued a guideline concerning UTI in children [4]. This promotes increased urine sampling, particularly from primary care. It advises against urine sampling if an alternative site of infection is identified.A recent review found that prevalences of UTI in children ranged from 2% to 20% [5]. Most of the included studies were from the US and included only febrile infants (temp >38°C; age <12 months). No studies have systematically sampled from consecutive acutely ill children in primary care, without selecting on the basis of presenting features.We do not know how often UTI is the cause of illness in young children presenting in general practice-based primary care and which children should be targeted for urine sampling. We conducted an exploratory study of the prevalence of UTI describing presenting symptoms and the proportion found to have a UTI when urine samples were systematically requested from all eligible children.     

Who receives anticoagulant treatment with warfarin and why? A population-based study in Finland

Objective

To ascertain the age and gender distribution of patients receiving anticoagulant (AC) treatment with warfarin, and to establish the prevalence of AC treatment and its indications among the Finnish population.

Design

A cross-sectional study in which the patients were identified from the patient records of health centres.

Setting

Primary health care in the Hospital District of South Ostrobothnia in Finland.

Patients

Those inhabitants of 15 municipalities in the study area who received AC treatment with warfarin on 1 April 2004. The total number of inhabitants was 132 621 at the end of 2003.

Main outcome measures

Patient age and gender distributions, the prevalence of AC treatment in the study area, and indications for AC treatment.

Results

Altogether 2389 patients were identified, 51.4% of them men. The mean age of the patients was 72.4 years. The prevalence of AC treatment was 1.8%; when age-adjusted to match the Finnish population it was 1.64%. The proportion of men receiving AC treatment was higher than that of women in all age groups. Atrial fibrillation (AF) was the most common main (60.2%) and second (7.2%) indication for AC treatment.

Conclusion

Compared with Finnish figures 12 years earlier the prevalence of AC treatment has more than doubled, and the proportion of AF among indications has increased from 47% to 67%. New current care guidelines on AF and the increasing proportion of the elderly among the population are probable explanations.Key Words: Anticoagulation treatment, atrial fibrillation, general practice, prevalence, primary health care, warfarinAccording to a Finnish study in 1992 the prevalence of anticoagulant (AC) treatment was 0.65% when age-adjusted to match the Finnish population. Atrial fibrillation was the most common main indication.

• According to the present study the prevalence of AC treatment has since more than doubled, being 1.64%.
• The proportion of atrial fibrillation among the indications for AC treatment has increased from 47% to 67%.
• About half of the patients were 75 years old or older.

Warfarin, a coumarin derivative, produces an anticoagulant effect by inhibiting the vitamin K conversion cycle [1]. The clinical effectiveness of oral anticoagulants has been established by well-designed clinical trials in a variety of disease conditions, e.g. for the prevention of systemic embolism in patients with atrial fibrillation. In 1992 the prevalence of anticoagulant (AC) treatment was 0.65% in a Finnish population study [2]. The most common main indication for this treatment was atrial fibrillation (38%) [3].The aim of this study was to establish the age and gender distributions of patients receiving AC treatment, and the prevalence of AC treatment in the study population. A further aim was to examine the indications for AC treatment.     

Assessment of cardiovascular risk in primary health care

Objective

This study aimed at investigating whether cardiovascular risk factors and their impact on total risk estimation differ between men and women.

Design

Cross-sectional cohort study.

Subjects

Finnish cardiovascular risk subjects (n = 904) without established cardiovascular disease, renal disease, or known diabetes.

Main outcome measures

Ankle-brachial index (ABI), estimated glomerular filtration rate (eGFR), oral glucose tolerance test, and total cardiovascular risk using SCORE risk charts.

Results

According to the SCORE risk charts, 27.0% (95% CI 23.1–31.2) of the women and 63.1% (95% CI 58.3–67.7) of the men (p < 0.001) were classified as high-risk subjects. Of the women classified as low-risk subjects according to SCORE, 25% had either subclinical peripheral arterial disease or renal insufficiency.

Conclusions

The SCORE system does not take into account cardiovascular risk factors typical in women, and thus underestimates their total cardiovascular risk. Measurement of ABI and eGFR in primary care might improve cardiovascular risk assessment. especially in women.Key Words: Ankle-brachial index, cardiovascular risk estimation, gender difference, glucose disorders, renal functionMore women than men die from cardiovascular disease in Europe, but the non-conventional risk factors in women may remain undiagnosed or ignored.

• In a cohort of middle-aged cardiovascular risk subjects in primary care, 27% of the women and 63% of the men (p < 0.001) were classified as high-risk subjects according to the SCORE risk charts.
• Of the women classified as low-risk subjects according to SCORE, 25% had either subclinical peripheral arterial disease or renal insufficiency.
• Measurement of ABI and eGFR in primary care might improve cardiovascular risk assessment, especially in women.