Consumption in out-of-hours health care: Danes double Dutch?

Objective. To study the quantitative consumption in out-of-hours (OOH) primary care in Denmark and the Netherlands, in the context of OOH care services. Design. A retrospective observational study describing contacts with OOH care services, using registration data. Setting. OOH care services (i.e. OOH primary care, emergency department, and ambulance care) in one Danish and one Dutch region. Subjects. All patients contacting the OOH care services in September and October 2011. Main outcome measures. Consumption as number of contacts per 1000 inhabitants in total and per age group per contact type. Results. For the two-month period the Danes had 80/1000 contacts with OOH primary care compared with 50/1000 for the Dutch. The number of contacts per 1000 inhabitants per age group varied between the regions, with the largest difference in the 0–5 years age group and a considerable difference in the young-adult groups (20–35 years). The difference was largest for telephone consultations (47/1000 vs. 20/1000), particularly in the youngest age group (154/1000 vs. 39/1000). The Danes also had more home visits than the Dutch (10/1000 vs. 5/1000), while the Dutch had slightly more clinic consultations per 1000 inhabitants than the Danes (25/1000 vs. 23/1000). Conclusion. The Danish population has more contacts with OOH primary care, particularly telephone consultations, especially concerning young patients. Future research should focus on the relevance of contacts and identification of factors related to consumption in OOH primary care.Key Words: After-hours care, Denmark, health services research, primary care, the Netherlands, utilization

• Danish and Dutch health care systems are quite comparable, having strong primary care and large-scale out-of-hours (OOH) primary care settings.
• National figures suggested that the Danish population has twice as many contacts with OOH primary care as the Dutch.
• A regional exploration confirmed this: the Danes generally had more OOH primary care contacts than the Dutch, particularly telephone consultations.
• The difference is most evident for the youngest patients, which may be explained by differences in organizational and patient-related factors.

     

The 30-day prognosis of chronic-disease patients after contact with the out-of-hours service in primary healthcare

Objective. Little is known about the prognosis of patients with chronic disease who contact the out-of-hours (OOH) service in primary care. The characteristics of contacts with the Danish out-of-hours service and daytime general practice, hospitalization, and death were studied during a 30-day follow-up period in patients with chronic heart diseases. Design. Cohort study. Setting and subjects. The study was based on data from 11 897 adults aged 18 + years from a Danish survey of OOH contacts, including information on consultation type. Reason for encounter (RFE) was categorized by OOH GPs at triage as either “exacerbation” or “new health problem”. Registry data were used to identify eligible patients, and the cohort was followed for 30 days after OOH contact through nationwide registries on healthcare use and mortality. Main outcome measures. The 30-day prognosis of chronic-disease patients after OOH contact. Results. Included patients with chronic disease had a higher risk of new OOH contact, daytime GP contact, and hospitalization than other patients during the 30-day follow-up period. OOH use was particularly high among patients with severe mental illness. A strong association was seen between chronic disease and risk of dying during follow-up. Conclusion. Patients with chronic disease used both daytime general practice and the out-of-hours service more often than others during the 30-day follow-up period; they were more often hospitalized and had higher risk of dying. The findings call for a proactive approach to future preventive day care and closer follow-up of this group, especially patients with psychiatric disease.Key Words: Chronic disease, Denmark, general practice, OOH, out-of-hours service, primary healthcare, reasons for encounter

• Limited knowledge exists on the prognosis of patients with chronic disease who attend out-of-hours (OOH) primary care.
• Patients with at least one out of five selected chronic diseases had higher OOH and GP use and also increased risk of hospitalization than other patients during the 30-day follow-up period.
• Patients with chronic disease in combination with OOH contact were at high risk of dying.
• The findings mandate more proactive approaches to future preventive day care and follow-up of patients with chronic disease.

     

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.

     

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.

     

Patient safety culture in Norwegian primary care: A study in out-of-hours casualty clinics and GP practices

Objective. This study aimed to investigate patient safety attitudes amongst health care providers in Norwegian primary care by using the Safety Attitudes Questionnaire, in both out-of-hours (OOH) casualty clinics and GP practices. The questionnaire identifies five major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, and Working conditions. Design. Cross-sectional study. Statistical analysis included multiple linear regression and independent samples t-tests. Setting. Seven OOH casualty clinics and 17 GP practices in Norway. Subjects. In October and November 2012, 510 primary health care providers working in OOH casualty clinics and GP practices (316 doctors and 194 nurses) were invited to participate anonymously. Main outcome measures. To study whether patterns in patient safety attitudes were related to professional background, gender, age, and clinical setting. Results. The overall response rate was 52%; 72% of the nurses and 39% of the doctors answered the questionnaire. In the OOH clinics, nurses scored significantly higher than doctors on Safety climate and Job satisfaction. Older health care providers scored significantly higher than younger on Safety climate and Working conditions. In GP practices, male health professionals scored significantly higher than female on Teamwork climate, Safety climate, Perceptions of management and Working conditions. Health care providers in GP practices had significant higher mean scores on the factors Safety climate and Working conditions, compared with those working in the OOH clinics. Conclusion. Our study showed that nurses scored higher than doctors, older health professionals scored higher than younger, male GPs scored higher than female GPs, and health professionals in GP practices scored higher than those in OOH clinics – on several patient safety factors.Key Words: Adverse events, general practice, medical errors, Norway, out-of-hours, patient safety culture, primary care, Safety Attitudes QuestionnairePatient safety culture is how leader and staff interaction, attitudes, routines, and practices in a group setting may protect patients from adverse events.

• In out-of-hours clinics, nurses scored higher than doctors, and older health professionals scored higher than younger on patient safety factors.
• Male professionals in GP practices scored significantly higher than female on four of the patient safety factors.
• Health care providers in GP practices had higher patient safety factor scores than those working in out-of-hours clinics.

     

Safety of telephone triage in out-of-hours care: a systematic review

Objective

Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care.

Methods

A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem).

Results

Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5–97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7–90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7–49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6).

Conclusions

There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.Key Words: After-hours care, emergency medical services, primary health care, safety, telephone, triageHow safe is telephone triage in out-of-hours care?

• Concerns have been expressed regarding the safety of telephone triage in out-of-hours care.
• We found that safety may be suboptimal in patients who present highly urgent symptoms. Improving safety poses a challenge given the low incidence of these patients.

     

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.

     

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.