No association between level of vitamin D and chronic low back pain in Swedish primary care: a cross-sectional case-control study

Objective: Assessment of vitamin D levels and deficiency status in individuals with chronic low back pain (CLBP) in a Swedish general population, compared with controls matched for sex and age.

Design: Cross-sectional case-control study.

Setting: Primary care, southern Sweden.

Subjects: Participants (n?=?44) with self-reported low back pain for at least 3 months and individually sex- and age-matched controls without a chronic pain condition (n?=?44), recruited from the general population by random letter of invitation.

Main outcome measure: Association between vitamin D level and CLBP when adjusting for possible confounders in a multivariate forward conditional logistic regression model.

Results: Mean S-25-hydroxyvitamin D levels were 81 and 80?nmol/L in the CLBP and control group, respectively. The prevalence of vitamin D deficiency was low and similar in the CLBP group and the control group. Vitamin D level was not associated with CLBP when potential confounders were taken into account.

Conclusions: No difference in vitamin D levels between participants with CLBP and matched controls could be demonstrated in the present sample. Assessment of vitamin D level and deficiency status may be of questionable value in the management of CLBP in primary care settings at similar latitudes, unless there are additional risk factors for deficiency or specific indicators of osteomalacia.

• Key Points

• Vitamin D deficiency is common and reported in many chronic pain conditions, including chronic low back pain (CLBP), but evidence for an association and causality is insufficient.

• The present study found no association between vitamin D levels and CLBP in a case-control sample of 44?+?44 individuals from the Swedish general population.

• Prevalence of vitamin D deficiency was low and comparable in individuals with CLBP and controls without chronic pain, matched for sex and age.

• Assessment of vitamin D status, for the purpose of finding and treating an underlying cause of pain, may be of limited value in the management of CLBP in primary care settings at similar latitudes.

     

Improving continuity of care across psychiatric and emergency services: combining patient data within a participatory action research framework

Presented with the concerns of emergency department nurses about providing appropriate and co-ordinated care for patients seeking mental health services, a Monash University School of Nursing, Victoria, Australia, research team chose a participatory action research strategy. Jointly executed with staff from the Peninsula Health Care Network, the research process brought together in a number of fora multiple disciplines involved in the care and management of psychiatric patients. The participatory action research process itself was the first step in remedial action. Through it, participants and management gained a firmer view of the issues facing Frankston Hospital Emergency Department staff in dealing with psychiatric patients, and in securing their access to suitable pathways of care. Other research outcomes included: a compilation of summary statistics showing patterns of use by psychiatric patients of Frankston Hospital's Emergency Department; beginning discussions about pathways of care for these patients; and the development of a screening tool to be used by the triage nurse for at-risk psychiatric patients presenting to the Emergency Department.     

Telemedicine consultations with physicians in Swedish primary care: a mixed methods study of users’ experiences and care patterns

ObjectiveThe study aimed to explore users’ experiences and care patterns concerning telemedicine consultations with physicians in Swedish primary care from 2017 to 2019.Design and participants: A mixed methods study involving 26 qualitative interviews with users of telemedicine consultations from a national sample, complemented by a quantitative registry study of data from 10,400 users in a Swedish region.ResultsUsers mainly described telemedicine consultations as a positive experience and perceived that the service met their current health care needs. Users also valued high accessibility, timesaving, and the contribution to ecological sustainability. Users felt competent about choosing when to use telemedicine consultations, most commonly for less severe health care concerns. This was confirmed by the quantitative results; only a few users had other care contacts within physical primary care before, or after, the telemedicine consultation, attended acute care or phoned 1177 Health Care Guidance.ConclusionsThis study provides a rare account of users’ experiences of telemedicine consultations. Users expressed satisfaction with this up-to-date use of health care resources for them as individuals, the health care system, and the environment. Telemedicine consultations were perceived as efficient and safe according to users. In addition, the study shows a low degree of further physical contacts in primary care or in acute care related to the telemedicine consultations.

Key points

• Users have positive experiences of telemedicine consultations with physicians and experienced that the service had meet their actual needs for health care.
• Users were mainly satisfied with the service and highlighted the value of high accessibility.
• Users experienced that telemedicine consultants provided an alternative care service for mostly minor health problems, perceiving them to save time and resources for themselves, the health care system, and the environment.
• Most telemedicine consultations did not result in additional contacts with 1177 Health Care Guidance, physical visits to primary care, or acute health care.
• Telemedicine consultations with physicians were mainly used by persons aged 0–30 years and need to be further developed to suit other age groups.

     

Harm caused by adverse events in primary care: a clinical observational study

Rationale, aims and objectives  Patient safety in primary care is important, but not well studied. The aim of our study was to determine the actual and potential harm caused by adverse events in primary care.
Method  Observational study in two general practices, including the patients of five doctors. Two methods were used to identify adverse events; (1) a prospective registration of adverse events by the general practitioner and (2) a retrospective audit of medical records. Actual harm was registered and a clinical analysis was made to estimate potential harm.
Results  A total of 31 adverse events were collected and analysed. The adverse events were spread over different adverse event categories. About half of the events did not have health consequences, but a third led to worsening of symptoms and a few resulted in unplanned hospital admission. Potential negative health consequences were likely in three-quarters of the events.
Conclusions  The identified adverse events had some impact on health outcomes, but a risk for harm existed in a majority of the events. Patient safety programmes in primary care should focus on adverse events and not just on harm.     

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study

Objective: Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor’s list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors’ services in collaborative parts of the health care system.

Design: An observational study.

Setting: Register-based retrospective quasi-experimental longitudinal follow-up study based on a before–after setting in a Finnish city.

Subjects: Patients who consulted different doctors in a local health care unit.

Main outcome measures: Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.

Results: The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.

Conclusions: The data suggested that the reverse triage causes redistribution of the use of doctors’ services rather than a true decrease in the use of these services.     

Visit patterns at primary care centres and individual blood pressure level – a cross-sectional study

Objective: Hypertension is a major cause of cardiovascular disease. Nevertheless, blood pressure (BP) is often inadequately treated. We studied visit patterns at primary health care centres (PHCCs) and their relation to individual BP control.

Design and setting: Cross-sectional register-based study on all patients with hypertension who visited 188 PHCCs in a Swedish region.

Patients: A total of 88,945 patients with uncomplicated hypertension age 40–79.

Main outcome measures: Odds ratio (OR) for the individual patient to achieve the BP target of ≤140/90?mmHg.

Results: Overall, 63% of patients had BP?≤?140/90?mmHg (48% BP?<?140/90). The PHCC that the patient was enrolled at and, as part of that, more nurse visits at PHCC level was associated with BP control, adjusted OR 1,10 (95% CI 1.01 to 1.21). Patients visiting PHCCs with the highest proportion of visits with nurses had an even higher chance of achieving the BP target, OR 1.19 (95% CI 1.07 to 1.32).

Conclusions: In a Swedish population of patients with hypertension, about half do not achieve recommended treatment goals. Organisation of PHCC and team care are known as factors influencing BP control. Our results suggests that a larger focus on PHCC organisation including nurse based care could improve hypertension care.     

The influence of electronic reminders on recording diagnoses in a primary health care emergency department: a register-based study in a Finnish town

ObjectiveThis study examines whether implementation of electronic reminders is associated with a change in the amount and content of diagnostic data recorded in primary health care emergency departments (ED).DesignA register-based 12-year follow-up study with a before-and-after design.SettingThis study was performed in a primary health care ED in Finland. An electronic reminder was installed in the health record system to remind physicians to include the diagnosis code of the visit to the health record.Subjects and main outcome measuresThe report generator of the electronic health record-system provided monthly figures for the number of different recorded diagnoses by using the International Classification of Diagnoses (ICD-10th edition) and the total number of ED physician visits, thus allowing the calculation of the recording rate of diagnoses on a monthly basis and the comparison of diagnoses before and after implementing electronic reminders.ResultsThe most commonly recorded diagnoses in the ED were acute upper respiratory infections of various and unspecified sites (5.8%), abdominal and pelvic pain (4.8%), suppurative and unspecified otitis media (4.5%) and dorsalgia (4.0%). The diagnosis recording rate in the ED doubled from 41.2 to 86.3% (p < 0.001) after the application of electronic reminders. The intervention especially enhanced the recording rate of symptomatic diagnoses (ICD-10 group-R) and alcohol abuse-related diagnoses (ICD-10 code F10). Mental and behavioural disorders (group F) and injuries (groups S-Y) were also better recorded after this intervention.ConclusionElectronic reminders may alter the documentation habits of physicians and recording of clinical data, such as diagnoses, in the EDs. This may be of use when planning resource managing in EDs and planning their actions.

KEY POINTS

• Electronic reminders enhance recording of diagnoses in primary care but what happens in emergency departments (EDs) is not known.
• Electronic reminders enhance recording of diagnoses in primary care ED.
• Especially recording of symptomatic diagnoses and alcohol abuse-related diagnoses increased.

     

Treatment,transport, and primary care involvement when helicopter emergency medical services are inaccessible: a retrospective study

Abstract

Objective: To examine handling of cancelled helicopter emergency medical services (HEMS) missions with a persisting medical indication.

Design: Retrospective observational study.

Setting and subjects: Cancelled HEMS missions with persisting medical indication within Sogn og Fjordane county in Norway during the period of 2010–2013. Both primary and secondary missions were included.

Main outcome measures: Primary care involvement, treatment and cooperation within the prehospital system.

Results: Our analysis included 172 missions with 180 patients. Two-thirds of the patients (118/180) were from primary missions. In 95% (112/118) of primary missions, GPs were alerted, and they examined 62% (70/112) of these patients. Among the patients examined by a GP, 30% (21/70) were accompanied by a GP during transport to hospital. GP involvement did not differ according to time of day (p?=?0.601), diagnostic group (p?=?0.309), or patient’s age (p?=?0.409). In 41% of primary missions, the patients received no treatment or oxygen only during transport. Among the secondary missions, 10% (6/62) of patients were intubated or received non-invasive ventilation and were accompanied by a physician or nurse anaesthetist during transport.

Conclusions: Ambulance workers and GPs have an important role when HEMS is unavailable. Our findings indicated good collaboration among the prehospital personnel. Many of the patients were provided minimal or no treatment, and treatment did not differ according to GP involvement.

• Key Points

• Knowledge about handling and involvement of prehospital services in cancelled helicopter emergency medical services (HEMS) missions are scarce.

• Ambulance workers and general practitioners have an important role when HEMS is unavailable

• Minimal or no treatment was given to a large amount of the patients, regardless of which health personnel who encountered the patient.

     

Use of faecal immunochemical tests common in patients with suspected colorectal cancer but unrelated to travel distance to secondary care: a population-based study from Swedish primary care

BackgroundEvidence is increasing for the use of faecal immunochemical tests (FITs) for occult blood as diagnostic tools when colorectal cancer can be suspected. FITs have been used for this purpose in Swedish primary care since around 2005 despite absence of supporting guidelines. To our knowledge, the extent of this use has not been studied.ObjectiveTo investigate the use of FITs as diagnostic tools, and if the use was related to patient age, sex and travel time from primary care to diagnostic facilities in secondary care.DesignPopulation-based retrospective study using data from electronic health records.Setting and subjectsPatients ≥18 years that provided FITs in primary care in five Swedish health care regions during 2015. Driving times from their primary care centres to secondary care were calculated.Main outcome measuresThe proportion of patients that provided FITs was calculated for each region, different age intervals and grouped driving times.Results18,913 patients provided FITs. The proportion of listed patients in the five regions that provided FITs increased with age: 0.86–1.2% for ages <65 years, 3.6–4.1% for ages 65–79 years and 3.8–6.1% for ages ≥80 years. Differences between the regions were small. There was no overall correlation between the proportion of patients that provided FITs and driving time to secondary care.ConclusionFITs were used extensively in Swedish primary care with a higher use in older age groups. There was no tendency towards a higher use of FITs at primary care centres with longer driving times to secondary care.

Key Points

• Evidence is increasing for the use of faecal immunochemical tests (FITs) as diagnostic tools when colorectal cancer can be suspected. We investigated the use of FITs in Sweden.
• FITs were used extensively in primary care especially in older age groups.
• There were small differences in the use of FITs between five studied health care regions.
• There was no tendency towards a higher use of FITs at primary care centres with longer driving times to diagnostic facilities in secondary care.

     

Palliative care case management in primary care settings: A nationwide survey

Background

In case management an individual or small team is responsible for navigating the patient through complex care. Characteristics of case management within and throughout different target groups and settings vary widely. Case management is relatively new in palliative care. Insight into the content of care and organisational characteristics of case management in palliative care is needed.

Objectives

To investigate how many case management initiatives for palliative care there are in the Netherlands for patients living at home; to describe the characteristics of these initiatives with regard to content and organisation of care.

Setting

Primary care.

Design and participants

A nationwide survey of all 50 coordinators of networks in palliative care in the Netherlands was conducted. Additional respondents were found through snowball sampling. We looked at 33 possible initiatives using interviews (n = 33) and questionnaires (n = 30).

Results

We identified 20 initiatives for case management. All stated that case management is supplemental to other care. In all initiatives the case managers are registered nurses and most possess higher vocational education and/or further training. All initiatives seek to identify the multidimensional care needs of the patients and the relatives and friends who care for them. Almost all provide information and support and refer patients who need care. Differences are found between the organisations offering the case management, their target groups, the names of the initiatives and whether direct patient care is provided by the case manager.

Conclusions

In the Netherlands, case management in palliative care is new. Several models of delivery were identified. Research is needed to gain insight into the best way to deliver case management. By describing characteristics of case management in palliative care, an important first step is made in identifying effective elements of case management.     

Frequent emergency department visitors are frequent primary care visitors and report unmet primary care needs

A small percentage of emergency department (ED) visitors account for a disproportionate portion of ED visits. Little is known about their relationships with their primary care providers (PCPs). This study compares frequent and infrequent ED visitors' primary care utilization and perceptions of primary care access, continuity, and connectedness and examines primary care utilization and perceptions as predictors of ED use. Data were obtained from 2 cross‐sectional studies of psychosocial predictors of high levels of utilization at 2 urban hospitals. Data included age, sex, race/ethnicity, number and type of chronic conditions, self‐rated health, and number of primary care and ED visits in the previous 12 months. Participants also answered 8 primary care access, continuity, and connectedness items. Participants with frequent ED visits (N = 70) were younger (43.24 vs 48.34, P = .020), more likely to be African American (61.4% vs 41.8%, P < .001), had a significant chronic illness burden (5.83 vs 2.83 chronic conditions, P < .001), and were more likely to report fair or poor health (65.7% vs 50.4%, P = .009). Frequent ED users were as likely as infrequent users to have a usual source of care, and reported similar primary care access, relationship length, and likelihood of provider knowing them well. Although making twice as many primary care visits, these participants were less likely to report that they could get what they need from their PCP (76.12% vs 92.53%, P < .001). Despite similar primary care access and continuity, frequent ED visitors are less likely to report that they get what they need from their PCPs. Further research should investigate their needs and how primary care can best provide high‐value care to this complex population.