1
|
Asheim A, Nilsen SM, Svedahl ER, Kaspersen SL, Bjerkeset O, Janszky I, Bjørngaard JH. Risk of suicide after hospitalizations due to acute physical health conditions-a cohort study of the Norwegian population. BMC Med 2024; 22:396. [PMID: 39285471 PMCID: PMC11406799 DOI: 10.1186/s12916-024-03623-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 09/09/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND It is well known that individuals recently discharged from psychiatric inpatient care face a high risk of suicide. Severe physical health conditions have also been linked to suicide risk. The risk of suicide following discharge from somatic hospitals is not known for individuals admitted due to acute physical health conditions. METHODS A Cohort study using data from the entire Norwegian population aged 12 years and older from 2008 to 2022 linked with information on health service use and cause of death. We used Cox regression with age as time axis to estimate sex-adjusted hazard ratios of suicide following discharge for ages 12 to 64 years and 65 years and older. We also performed analyses after excluding hospitalizations with indications of concurrent mental disorders, self-harm, or suicide attempts. To assess individual risk, we performed an adapted case-crossover analysis among discharged patients who died from suicide. RESULTS A total of 4 632,980 individuals aged 12 to 64 years and 1,469,265 individuals aged 65 years and older were included. Compared to unexposed individuals at similar ages, we found an increased risk of suicide in the first 4 weeks after discharge, with a hazard ratio (HR) of 7.0 (95% confidence interval (CI) 5.9 to 8.3) among those aged 12 to 64 years and 6.8 (95% CI 5.4 to 8.6) among those 65 years and older. In the younger age group, the risk was attenuated, with a HR of 2.4 (95% CI 1.7 to 3.2) after excluding hospitalizations with indications of concurrent mental disorders, self-harm, or suicide attempts. The corresponding HR was 4.8 (95% CI 3.5 to 6.4) among those 65 years and older, declining to 1.9, (1.2 to 3.1) in weeks 5 to 8 and 1.2 (0.7 to 2.2) in weeks 21 to 24. The case-crossover analysis confirmed that individuals 65 years and older were particularly vulnerable. CONCLUSIONS The heightened risk of suicide following discharge from acute somatic hospitalization, even in the absence of concurrent mental disorders, self-harm, or prior suicide attempts, underscores the critical need for comprehensive mental health and existential support for patients post-discharge.
Collapse
Affiliation(s)
- Andreas Asheim
- Regionalt Senter for Helsetjenesteutvikling, St. Olavs Hospital, Postboks 3250 Sluppen, Trondheim, N-7006, Norway
| | - Sara Marie Nilsen
- Regionalt Senter for Helsetjenesteutvikling, St. Olavs Hospital, Postboks 3250 Sluppen, Trondheim, N-7006, Norway
| | - Ellen Rabben Svedahl
- NTNU, Institutt for Samfunnsmedisin Og Sykepleie, Postboks 8905, Trondheim, 7491, Norway
| | - Silje L Kaspersen
- NTNU, Institutt for Samfunnsmedisin Og Sykepleie, Postboks 8905, Trondheim, 7491, Norway
| | - Ottar Bjerkeset
- Faculty of Nursing and Health Sciences, Nord University, PB 93, Levanger, 7601, Norway
| | - Imre Janszky
- NTNU, Institutt for Samfunnsmedisin Og Sykepleie, Postboks 8905, Trondheim, 7491, Norway
| | - Johan Håkon Bjørngaard
- NTNU, Institutt for Samfunnsmedisin Og Sykepleie, Postboks 8905, Trondheim, 7491, Norway.
| |
Collapse
|
2
|
Søvsø MB, Haurum RB, Ebbesen TH, Rasmussen AØ, Ward LM, Mogensen ML, Christensen EF, Lindskou TA. Emergency Call versus General Practitioner Requested Ambulances - Patient Mortality, Disease Severity and Pattern. Clin Epidemiol 2024; 16:513-523. [PMID: 39101155 PMCID: PMC11297546 DOI: 10.2147/clep.s469430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/06/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction Ambulance requests by general practitioners for primary care patients (GP-requested) are often omitted in studies on increased demand within emergency care but may comprise a substantial patient group. We aimed to assess acute severity, intensive care unit (ICU) admission, and diagnostic pattern, including comorbidity, and mortality among GP-requested ambulance patients, compared to emergency call ambulance patients. Our hypothesis was that emergency call patients had more severe health issues than GP-requested ambulance patients. Methods Historic population-based cohort study of ambulance patients in the North Denmark Region, 2016-2020. Hospital contact data including diagnoses, ambulance data, vital signs and vital status was linked using each patient's unique identification number. Primary outcome measure was mortality within 1, 7, and 30 days. Secondary outcomes were disease severity expressed as modified National Early Warning Score (NEWS2), and ICU admission. Admission status and hospital diagnostic pattern, including comorbidity were described and compared. Results We included 255,487 patients. GP-requested patients (N = 119,361, 46.7%) were older (median years [IQR] 73 [58-83] versus 61 [37-76]) and more had moderate/severe comorbidity (11.9%, N = 13,806 versus 4.9%, N = 6145) than the emergency call patients. Prehospital mNEWS2 median scores were lower for GP-requested patients. For both groups, mNEWS2 was highest among patients aged 66+. GP-requested patients had higher 30-day mortality (9.0% (95% CI: 8.8-9.2), N = 8996) than emergency call patients (5.2% (95% CI: 5.1-5.4), N = 6727). Circulatory (12.0%, 11,695/97,112) and respiratory diseases (11.6%, 11,219/97,112) were more frequent among GP-requested patients than emergency call patients ((10.7%, 12,640/118,102) and (5.8%, 6858/118,102)). The highest number of deaths was found for health issues 'circulatory diseases' in the emergency call group and 'other factors' followed by "respiratory diseases" in the GP-requested group. Conclusion GP-requested patients constituted nearly half of the EMS volume, they were older, with more comorbidity, had serious conditions with substantial acute severity, and a higher 30-day mortality than emergency call patients.
Collapse
Affiliation(s)
- Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research at Danish Centre for Health Services Research; Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Gistrup, Denmark
| | - Rasmine Birch Haurum
- Department of Health, Science and Technology, Aalborg University, Gistrup, Denmark
| | | | - Ann Øster Rasmussen
- Department of Health, Science and Technology, Aalborg University, Gistrup, Denmark
| | | | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research at Danish Centre for Health Services Research; Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Gistrup, Denmark
| | - Tim Alex Lindskou
- Centre for Prehospital and Emergency Research at Danish Centre for Health Services Research; Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Gistrup, Denmark
| |
Collapse
|
3
|
Weghorst AAH, Sanci LA, Berger MY, Hiscock H, Jansen DEMC. Comparing healthcare systems between the Netherlands and Australia in management for children with acute gastroenteritis. PLoS One 2024; 19:e0306739. [PMID: 39046987 PMCID: PMC11268636 DOI: 10.1371/journal.pone.0306739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/22/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Acute gastroenteritis is a highly contagious disease demanding effective public health and clinical care systems for prevention and early intervention to avoid outbreaks and symptom deterioration. The Netherlands and Australia are both top-performing, high-income countries where general practitioners (GPs) act as healthcare gatekeepers. However, there is a lower annual incidence and per-case costs for childhood gastroenteritis in Australia. Understanding the systems and policies in different countries can lead to improvements in processes and care. Therefore, we aimed to compare public health systems and clinical care for children with acute gastroenteritis in both countries. METHODS A cross-country expert study was conducted for the Netherlands and Australia. Using the Health System Performance Assessment framework and discussions within the research group, two questionnaires (public health and clinical care) were developed. Questionnaires were delivered to local experts in the Netherlands and the state of Victoria, Australia. Data synthesis employed a narrative approach with constant comparison. RESULTS In Australia, rotavirus vaccination is implemented in a national program with immunisation requirements and legislation for prevention, which is not the case in the Netherlands. Access to care differs, as Dutch children must visit their regular GP before the hospital, while in Australia, children have multiple options and can go directly to hospital. Funding varies, with the Netherlands providing fully funded healthcare for children, whilst in Australia it depends on which GP (co-payment required or not) and hospital (public or private) they visit. Additionally, the guideline-recommended dosage of the antiemetic ondansetron is lower in the Netherlands. CONCLUSIONS Healthcare approaches for managing childhood gastroenteritis differ between the Netherlands and Australia. The lower annual incidence and per-case costs for childhood gastroenteritis in Australia cannot solely be explained by the differences in healthcare system functions. Nevertheless, Australia's robust public health system, characterized by legislation for vaccinations and quarantine, and the Netherland's well-established clinical care system, featuring fully funded continuity of care and lower ondansetron dosages, offer opportunities for enhancing healthcare in both countries.
Collapse
Affiliation(s)
- Anouk A. H. Weghorst
- Department of Primary and Long-Term Care, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lena A. Sanci
- Department of General Practice, University of Melbourne, Parkville, Victoria, Australia
| | - Marjolein Y. Berger
- Department of Primary and Long-Term Care, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Harriet Hiscock
- Murdoch Children’s Research Institute, Health Services Research Group, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Danielle E. M. C. Jansen
- Department of Primary and Long-Term Care, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| |
Collapse
|
4
|
Myklevoll KR, Zakariassen E, Morken T, Baste V, Blinkenberg J, Bondevik GT. Primary care doctors in acute call-outs to severe trauma incidents in Norway - variations by rural-urban settings and time factors. BMC Emerg Med 2024; 24:107. [PMID: 38926855 PMCID: PMC11209977 DOI: 10.1186/s12873-024-01027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND A severely injured patient needs fast transportation to a hospital that can provide definitive care. In Norway, approximately 20% of the population live in rural areas. Primary care doctors (PCDs) play an important role in prehospital trauma care. The aim of this study was to investigate how variations in PCD call-outs to severe trauma incidents in Norway were associated with rural-urban settings and time factors. METHODS In this study on severe trauma patients admitted to Norwegian hospitals from 2012 to 2018, we linked data from four official Norwegian registries. Through this, we investigated the call-out responses of PCDs to severe trauma incidents. In multivariable log-binomial regression models, we investigated whether factors related to rural-urban settings and time factors were associated with PCD call-outs. RESULTS There was a significantly higher probability of PCD call-outs to severe trauma incidents in the municipalities in the four most rural centrality categories compared to the most urban category. The largest difference in adjusted relative risk (95% confidence interval (CI)) was 2.08 (1.27-3.41) for centrality category four. PCDs had a significantly higher proportion of call-outs in the Western (RR = 1.46 (1.23-1.73)) and Central Norway (RR = 1.30 (1.08-1.58)) Regional Health Authority areas compared to in the South-Eastern area. We observed a large variation (0.47 to 4.71) in call-out rates to severe trauma incidents per 100,000 inhabitants per year across the 16 Emergency Medical Communication Centre areas in Norway. CONCLUSIONS Centrality affects the proportion of PCD call-outs to severe trauma incidents, and call-out rates were higher in rural than in urban areas. We found no significant difference in call-out rates according to time factors. Possible consequences of these findings should be further investigated.
Collapse
Affiliation(s)
- Kristian Rikstad Myklevoll
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Postbox 7804, Bergen, N-5020, Norway.
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Postbox 22 Nygårdstangen, Bergen, N-5838, Norway.
| | - Erik Zakariassen
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Postbox 7804, Bergen, N-5020, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Postbox 22 Nygårdstangen, Bergen, N-5838, Norway
| | - Tone Morken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Postbox 22 Nygårdstangen, Bergen, N-5838, Norway
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Postbox 22 Nygårdstangen, Bergen, N-5838, Norway
| | - Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Postbox 22 Nygårdstangen, Bergen, N-5838, Norway
| | - Gunnar Tschudi Bondevik
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Postbox 7804, Bergen, N-5020, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Postbox 22 Nygårdstangen, Bergen, N-5838, Norway
| |
Collapse
|
5
|
Harðardóttir GH, Petersen JS, Krarup AL, Christensen EF, Søvsø MB. Deaths Among Ambulance Patients Released from the Emergency Department Within the First 24 Hours With Nonspecific Diagnoses - Expected or Not? J Emerg Med 2024; 66:e571-e580. [PMID: 38693006 DOI: 10.1016/j.jemermed.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 05/03/2024]
Abstract
BACKGROUND Emergency patients are frequently assigned nonspecific diagnoses. Nonspecific diagnoses describe observations or symptoms and are found in chapters R and Z of the International Classification of Diseases, 10th edition (ICD-10). Patients with such diagnoses have relatively low mortality, but due to patient volume, the absolute number of deaths is substantial. However, information on cause of short-term mortality is limited. OBJECTIVES To investigate whether death could be expected for ambulance patients brought to the emergency department (ED) after a 1-1-2 call, released with a nonspecific ICD-10 diagnosis within 24 h, and who subsequently died within 30 days. METHODS Retrospective medical record review of adult 1-1-2 emergency ambulance patients brought to an ED in the North Denmark Region during 2017-2021. Patients were divided into three categories: unexpected death, expected death (terminal illness), and miscellaneous. Charlson Comorbidity Index (CCI) was assessed. RESULTS We included 492 patients. Mortality was distributed as follows: Unexpected death 59.2% (n = 291), expected death (terminal illness) 25.8% (n = 127), and miscellaneous 15.0% (n = 74). Patients who died unexpectedly were old (median age of 82 years) and had CCI 1-2 (58.1%); 43.0% used at least five daily prescription drugs, and they were severely acutely ill upon arrival (24.7% with red triage, 60.1% died within 24 h). CONCLUSIONS More than half of ambulance patients released within 24 h from the ED with nonspecific diagnoses, and who subsequently died within 30 days, died unexpectedly. One-fourth died from a pre-existing terminal illness. Patients dying unexpectedly were old, treated with polypharmacy, and often life-threateningly sick at arrival.
Collapse
Affiliation(s)
- Guðný Halla Harðardóttir
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Johnny Strøm Petersen
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Anne L Krarup
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Aalborg, Denmark
| | - Erika F Christensen
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Morten B Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
6
|
Gamboa D, Kabashi S, Jørgenrud B, Lerdal A, Nordby G, Bogstrand ST. Is alcohol and psychoactive medication use associated with excess hospital length-of-stay and admission frequency? A cross-sectional, observational study. BMC Emerg Med 2024; 24:63. [PMID: 38627626 PMCID: PMC11020419 DOI: 10.1186/s12873-024-00979-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/28/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Hospital length-of-stay and admission frequency are commonly used indicators of disease burden and health resource expenditures. However, the impact of psychoactive prescription medication use and harmful alcohol consumption on both the duration and frequency of hospital admissions is under-explored. METHODS We conducted an analysis of data gathered from 2872 patients admitted to the Emergency Department at Lovisenberg Diaconal Hospital in Oslo, Norway. Psychoactive medicines (benzodiazepines, opioids, and z-hypnotics) were detected via liquid chromatography-mass spectrometry analysis of whole blood, while alcohol consumption was self-reported through the Alcohol Use Disorder Identification Test-4 (AUDIT-4). Using logistic regression, we examined associations with our primary outcomes, which were excess length-of-stay and admission frequency, defined as exceeding the sample median of 3.0 days and 0.2 admissions per year, respectively. RESULTS Compared to the absence of psychoactive medication, and after adjusting for age, gender, malignant disease, pre-existing substance use disorder and admission due to intoxication, the detection of two or more psychoactive medicines was associated with both excess length-of-stay (odds ratio [OR], 1.60; 95% confidence interval [CI], 1.20 to 2.14) and yearly hospitalization rate (OR, 3.72; 95% CI, 2.64 to 5.23). This association persisted when increasing the definition for excess length-of-stay to 4 and 5 days and to 1.0 and 1.5 admissions per year for admission frequency. Harmful alcohol consumption (AUDIT-4 scores of 9 to 16) was not associated with excess length-of-stay, but with excess admission frequency when defined as more than 1.0 admission per year when compared to scores of 4 to 6 (OR, 2.68; 95% CI, 1.58 to 4.57). CONCLUSIONS Psychoactive medication use is associated with both excess length-of-stay and increased antecedent admission frequency, while harmful alcohol consumption may be associated with the latter. The utility of our findings as a causal factor should be explored through intervention-based study designs.
Collapse
Affiliation(s)
- Danil Gamboa
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway.
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway.
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Saranda Kabashi
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Benedicte Jørgenrud
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anners Lerdal
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Research Department, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Gudmund Nordby
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
7
|
Wiik AB, Doupe MB, Bakken MS, Kittang BR, Jacobsen FF, Førland O. Areas of consensus on unwarranted and warranted transfers between nursing homes and emergency care facilities in Norway: a Delphi study. BMC Health Serv Res 2024; 24:374. [PMID: 38532452 PMCID: PMC10964583 DOI: 10.1186/s12913-024-10879-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Transferring residents from nursing homes (NHs) to emergency care facilities (ECFs) is often questioned as many are terminally ill and have access to onsite care. While some NH to ECF transfers have merit, avoiding other transfers may benefit residents and reduce healthcare system costs and provider burden. Despite many years of research in this area, differentiating warranted (i.e., appropriate) from unwarranted NH to ECF transfers remains challenging. In this article, we report consensus on warranted and unwarranted NH to ECF transfers scenarios. METHODS A Delphi study was used to identify consensus regarding warranted and unwarranted NH to ECF transfers. Delphi participants included nurses (RNs) and medical doctors (MDs) from NHs, out-of-hours primary care clinics (OOHs), and hospital-based emergency departments. A list of 12 scenarios and 11 medical conditions was generated from the existing literature on causes and medical conditions leading to transfers, and pilot tested and refined prior to conducting the study. Three Delphi rounds were conducted, and data were analyzed using descriptive and comparative statistics. RESULTS Seventy-nine experts consented to participate, of whom 56 (71%) completed all three Delphi rounds. Participants reached high or very high consensus on when to not transfer residents, except for scenarios regarding delirium, where only moderate consensus was attained. Conversely, except when pain relieving surgery was required, participants reached low agreement on scenarios depicting warranted NH to ECF transfers. Consensus opinions differ significantly between health professionals, participant gender, and rurality, for seven of the 23 transfer scenarios and medical conditions. CONCLUSIONS Transfers from nursing homes to emergency care facilities can be defined as warranted, discretionary, and unwarranted. These categories are based on the areas of consensus found in this Delphi study and are intended to operationalize the terms warranted and unwarranted transfers between nursing homes and emergency care facilities.
Collapse
Affiliation(s)
- Arne Bastian Wiik
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway.
| | - Malcolm Bray Doupe
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Marit Stordal Bakken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Bård Reiakvam Kittang
- University of Bergen, Bergen, Norway
- Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Frode Fadnes Jacobsen
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway
| | - Oddvar Førland
- Centre for Care Research, West. Western, Norway University of Applied Sciences, Bergen, Norway
| |
Collapse
|
8
|
Blinkenberg J, Hetlevik Ø, Sandvik H, Baste V, Hunskaar S. The impact of variation in out-of-hours doctors' referral practices: a Norwegian registry-based observational study. Fam Pract 2023; 40:728-736. [PMID: 36801994 PMCID: PMC10745277 DOI: 10.1093/fampra/cmad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND In a gatekeeping system, the individual doctor's referral practice is an important factor for hospital activity and patient safety. OBJECTIVE The aim of the study was to investigate the variation in out-of-hours (OOH) doctors' referral practice, and to explore these variations' impact on admissions for selected diagnoses reflecting severity, and 30-day mortality. METHODS National data from the doctors' claims database were linked with hospital data in the Norwegian Patient Registry. Based on the doctor's individual referral rate adjusted for local organizational factors, the doctors were sorted into quartiles of low-, medium-low-, medium-high-, and high-referral practice. The relative risk (RR) for all referrals and for selected discharge diagnoses was calculated using generalized linear models. RESULTS The OOH doctors' mean referral rate was 110 referrals per 1,000 consultations. Patients seeing a doctor in the highest referring practice quartile had higher likelihood of being referred to hospital and diagnosed with the symptom of pain in throat and chest, abdominal pain, and dizziness compared with the medium-low quartile (RR 1.63, 1.49, and 1.95). For the critical conditions of acute myocardial infarction, acute appendicitis, pulmonary embolism, and stroke, we found a similar, but weaker, association (RR 1.38, 1.32, 1.24, and 1.19). The 30-day mortality among patients not referred did not differ between the quartiles. CONCLUSIONS Doctors with high-referral practice referred more patients who were later discharged with all types of diagnoses, including serious and critical conditions. With low-referral practice, severe conditions might have been overlooked, although the 30-day mortality was not affected.
Collapse
Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009 Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009 Bergen, Norway
| |
Collapse
|
9
|
Thulin IVL, Jordalen SMF, Lekven OC, Krishnapillai J, Steiro OT, Collinson P, Apple F, Cullen L, Norekvål TM, Wisløff T, Vikenes K, Omland T, Bjørneklett RO, Aakre KM. Aiming toWards Evidence baSed inTerpretation of Cardiac biOmarkers in patients pResenting with chest pain using Point of Care Testing (WESTCOR-POC): study design. SCAND CARDIOVASC J 2023; 57:2272585. [PMID: 37905548 DOI: 10.1080/14017431.2023.2272585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVES Patients presenting with symptoms suggestive of acute coronary syndrome (ACS) contribute to a high workload and overcrowding in the Emergency Department (ED). Accelerated diagnostic protocols for non-ST-elevation myocardial infarction have proved challenging to implement. One obstacle is the turnaround time for analyzing high-sensitivity cardiac troponin (hs-cTn). In the WESTCOR-POC study (Clinical Trials number NCT05354804) we aim to evaluate safety and efficiency of a 0/1 h hs-cTn algorithm utilizing a hs-cTnI point of care (POC) instrument in comparison to central laboratory hs-cTnT measurements. DESIGN This is a prospective single-center randomized clinical trial aiming to include 1500 patients admitted to the ED with symptoms suggestive of ACS. Patients will receive standard investigations following the European Society of Cardiology 0/1h protocols for centralized hs-cTnT measurements or the intervention using a 0/1h POC hs-cTnI algorithm. Primary end-points are 1) Safety; death, myocardial infarction or acute revascularization within 30 days 2) Efficiency; length of stay in the ED, 3) Cost- effectiveness; total episode cost, 4) Patient satisfaction, 5) Patient symptom burden and 6) Patients quality of life. Secondary outcomes are 12-months death, myocardial infarction or acute revascularization, percentage discharged after 3 and 6 h, total length of hospital stay and all costs related to hospital contact within 12 months. CONCLUSION Results from this study may facilitate implementation of POC hs-cTn testing assays and accelerated diagnostic protocols in EDs, and may serve as a valuable resource for guiding future investigations for the use of POC high sensitivity troponin assays in outpatient clinics and prehospital settings.
Collapse
Affiliation(s)
| | | | - Ole Christian Lekven
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jeyaseelan Krishnapillai
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ole Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Fred Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN, USA
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjørn Wisløff
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rune O Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
10
|
Sørensen MC, Søvsø MB, Christensen EF, Lindskou TA. Critically deviating vital signs among patients with non-specific diagnoses-A register-based historic cohort study. PLoS One 2023; 18:e0293762. [PMID: 37910584 PMCID: PMC10619789 DOI: 10.1371/journal.pone.0293762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/19/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND One third of ambulance patients receive non-specific diagnoses in hospital. Mortality is 3-4%, however due to the high patient volume this group accounts for 20% of all deaths at day 30. Non-specific diagnoses do not provide much information on causes for death. Vital signs at first contact with ambulance personnel can act as a proxy for the patient's condition. Thus, we aimed to describe the prevalence of abnormal vital signs, as determined by a modified NEWS2, in ambulance patients who received a non-specific hospital diagnosis. Secondly, we examined the association between vital signs, NEWS2 scores, type of non-specific diagnosis, and mortality among these patients. METHODS Register-based historic cohort study of ambulance patients aged 16+ in the North Denmark Region during 2012-2016, who received a non-specific diagnosis (ICD-10 chapters R or Z) at hospital. We used NEWS2 scores to determine if first vital signs were normal or deviating (including critical). Mortality was estimated with the Kaplan-Meier estimator. Association between vital signs and mortality was evaluated by logistic regression. RESULTS We included 41,539 patients, 20.9% (N = 8,691) had normal vital signs, 16.3% (N = 6,766) had incomplete vital sign registration, 62.8% (N = 26,082) had deviating vital signs, and of these 6.8% (N = 1,779) were critical. If vital signs were incompletely registered or deviating, mortality was higher compared to normal vital signs. Patients with critical vital signs displayed the highest crude 48-hour and 30-day mortality (7.0% (5.9-8.3) and 13.4% (11.9-15.1)). Adjusting for age, sex, and comorbidity did not change that pattern. Across all vital sign groups, despite severity, the most frequent diagnosis assigned was Z039 observation for suspected disease or condition unspecified. CONCLUSIONS Most ambulance patients with non-specific diagnoses had normal or non-critical deviating vital signs and low mortality. Around 4% had critical vital signs and high mortality, not explained by age or comorbidity.
Collapse
Affiliation(s)
- Mia Carøe Sørensen
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
- Department of Emergency and Trauma Care, Clinic of Internal and Emergency Medicine, Aalborg, Denmark
| | - Tim Alex Lindskou
- Centre for Prehospital and Emergency Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
11
|
Myklevoll KR, Zakariassen E, Morken T, Baste V, Blinkenberg J, Bondevik GT. Primary care doctors in acute call-outs to severe trauma incidents in Norway - associations with factors related to patients and doctors. Scand J Prim Health Care 2023; 41:196-203. [PMID: 37256689 PMCID: PMC10478583 DOI: 10.1080/02813432.2023.2216235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/16/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE Severe trauma patients need immediate prehospital intervention and transfer to a specialised trauma hospital. In Norway, primary care doctors (PCDs) are an integrated part of the prehospital trauma care. The aim of this study was to investigate the degree to which PCDs were involved in prehospital care of severe trauma patients and how factors related to patients and doctors were associated with call-outs to these incidents. DESIGN This was a registry-based study in Norway on severe trauma patients with acute hospital admission during the period 2012-2018. SETTING Data was obtained from three Norwegian official registries. SUBJECTS By linking the registries, we studied the actions taken by the PCDs, whether they called out to severe trauma incidents. MAIN OUTCOME MEASURES In multivariable regression models, we investigated whether factors related to the PCDs (age, sex, specialisation in general practice (GP)) and patients (age, sex, duration of hospital stay, type of injury) were associated with call-outs. RESULTS Out of 4342 severe trauma incidents, PCDs had documented involvement in 1683 (39%) and called out to 644 (15%). Increased proportions of PCD call-outs to severe trauma incidents were significantly associated with lower age of PCD, being a GP specialist, lower patient age, being a male patient, increased length of hospital stay and injuries to the head and the neck. CONCLUSIONS PCDs called out to a relatively low proportion of severe trauma patients. Several factors related to patients and doctors were associated with call-outs to severe trauma incidents in Norway.
Collapse
Affiliation(s)
- Kristian Rikstad Myklevoll
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Erik Zakariassen
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Tone Morken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Gunnar Tschudi Bondevik
- Section for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| |
Collapse
|
12
|
Kolnes J, Hodneland E, Lange A, Heggestad T. Assessing competence needs for doctors in the emergency department duty rosters: an observational study. Int J Emerg Med 2023; 16:39. [PMID: 37340351 DOI: 10.1186/s12245-023-00515-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/11/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND The purpose of our investigation is to analyze if emergency epidemiology is randomly variable or predictable. If emergency admissions show a predictable pattern, we can use it for multiple planning purposes, especially defining competence needs for duty roster personnel. METHOD An observational study of consecutive emergency admissions at Haukeland University Hospital in Bergen over six years. We extracted the discharge diagnoses from our electronic patient record and sorted the patients by diagnoses and frequency. Data were loaded into a Jupyter notebook and presented in form of frequency diagrams. The study population, 213,801 patients, comprises all emergency admissions in need of secondary emergency care from the relevant specialities in the catchment area of our hospital in the western health region of Norway. Patients in need of tertiary care from the whole region are also included. RESULTS Our analysis shows an annually reproducible distribution pattern regarding type and number of patients. The pattern adhere to an exponential curve that is stable from year to year. An exponential distribution pattern also applies when we sort patients according to the capital letters groups in the ICD 10 system. The same applies if patients are sorted adhering to primarily surgical or medical diagnoses. CONCLUSION Analysis of the emergency epidemiology of all admitted emergency patients in a defined geographical area gives a solid basis for defining competence needs for duty roster work.
Collapse
Affiliation(s)
- Johannes Kolnes
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway.
| | - Erlend Hodneland
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Audun Lange
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Torhild Heggestad
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
13
|
Markussen DL, Brevik HS, Bjørneklett RO, Engan M. Validation of a modified South African triage scale in a high-resource setting: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:13. [PMID: 36941710 PMCID: PMC10026449 DOI: 10.1186/s13049-023-01076-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/04/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Triage systems are widely used in emergency departments, but are not always validated. The South African Triage Scale (SATS) has mainly been studied in resource-limited settings. The aim of this study was to determine the validity of a modified version of the SATS for the general population of patients admitted to an ED at a tertiary hospital in a high-income country. The secondary objective was to study the triage performance according to age and patient categories. METHODS We conducted a retrospective cohort study of patients presenting to the Emergency Department of Haukeland University Hospital in Norway during a four-year period. We used short-term mortality, ICU admission, and the need for immediate surgery and other interventions as the primary endpoints. RESULTS A total of 162,034 emergency department visits were included in the analysis. The negative predictive value of a low triage level to exclude severe illness was 99.1% (95% confidence interval: 99.0-99.2%). The level of overtriage, defined as the proportion of patients assigned to a high triage level who were not admitted to the hospital, was 4.1% (3.9-4.2%). Receiver operating characteristic (ROC) curves showed an area under the ROC for the detection of severe illness of 0.874 (95% confidence interval: 0.870-0.879) for all patients and 0.856 (0.837-0.875), 0.884 (0.878-0.890) and 0.869 (0.862-0.876) for children, adults and elderly individuals respectively. CONCLUSION We found that the modified SATS had a good sensitivity to identify short-term mortality, ICU admission, and the need for rapid surgery and other interventions. The sensitivity was higher in adults than in children and higher in medical patients than in surgical patients. The over- and undertriage rates were acceptable.
Collapse
Affiliation(s)
- Dagfinn Lunde Markussen
- Emergency Care Clinic, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway.
| | | | - Rune Oskar Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Postboks 7804, 5020, Bergen, Norway
| | - Mette Engan
- Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, 5021, Bergen, Norway
| |
Collapse
|
14
|
Johannessen TR, Halvorsen S, Atar D, Munkhaugen J, Nore AK, Wisløff T, Vallersnes OM. Cost-effectiveness of a rule-out algorithm of acute myocardial infarction in low-risk patients: emergency primary care versus hospital setting. BMC Health Serv Res 2022; 22:1274. [PMID: 36271364 PMCID: PMC9587629 DOI: 10.1186/s12913-022-08697-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
Aims Hospital admissions of patients with chest pain considered as low risk for acute coronary syndrome contribute to increased costs and crowding in the emergency departments. This study aims to estimate the cost-effectiveness of assessing these patients in a primary care emergency setting, using the European Society of Cardiology (ESC) 0/1-h algorithm for high-sensitivity cardiac troponin T, compared to routine hospital management. Methods A cost-effectiveness analysis was conducted. For the primary care estimates, costs and health care expenditure from the observational OUT-ACS (One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome) study were compared with anonymous extracted administrative data on low-risk patients at a large general hospital in Norway. Patients discharged home after the hs-cTnT assessment were defined as low risk in the primary care cohort. In the hospital setting, the low-risk group comprised patients discharged with a non-specific chest pain diagnosis (ICD-10 codes R07.4 and Z03.5). Loss of health related to a potential increase in acute myocardial infarctions the following 30-days was estimated. The primary outcome measure was the costs per quality-adjusted life year (QALY) of applying the ESC 0/1-h algorithm in primary care. The secondary outcomes were health care costs and length of stay in the two settings. Results Differences in costs comprise personnel and laboratory costs of applying the algorithm at primary care level (€192) and expenses related to ambulance transports and complete hospital costs for low-risk patients admitted to hospital (€1986). Additional diagnostic procedures were performed in 31.9% (181/567) of the low-risk hospital cohort. The estimated reduction in health care cost when using the 0/1-h algorithm outside of hospital was €1794 per low-risk patient, with a mean decrease in length of stay of 18.9 h. These numbers result in an average per-person QALY gain of 0.0005. Increased QALY and decreased costs indicate that the primary care approach is clearly cost-effective. Conclusion Using the ESC 0/1-h algorithm in low-risk patients in emergency primary care appears to be cost-effective compared to standard hospital management, with an extensive reduction in costs and length of stay per patient.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08697-6.
Collapse
Affiliation(s)
- Tonje R Johannessen
- Department of General Practice, Institute of Health and Society, University of Oslo, 1130 Blindern, 0318, Oslo, NO, Norway. .,Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway.
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - John Munkhaugen
- Department of Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Behavioural Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Kathrine Nore
- Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| | - Torbjørn Wisløff
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Odd Martin Vallersnes
- Department of General Practice, Institute of Health and Society, University of Oslo, 1130 Blindern, 0318, Oslo, NO, Norway.,Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| |
Collapse
|
15
|
Pahlavanyali S, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity of care for patients with chronic disease: a registry-based observational study from Norway. Fam Pract 2022; 39:570-578. [PMID: 34536072 PMCID: PMC9295609 DOI: 10.1093/fampra/cmab107] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Continuity of care (CoC) is accepted as a core value of primary care and is especially appreciated by patients with chronic conditions. Nevertheless, there are few studies investigating CoC for these patients across levels of healthcare. OBJECTIVE This study aims to investigate CoC for patients with somatic chronic diseases, both with regular general practitioners (RGPs) and across care levels. METHODS We conducted a registry-based observational study by using nationwide consultation data from Norwegian general practices, out-of-hours services, hospital outpatient care, and private specialists with public contracts. Patients with diabetes mellitus (type I or II), asthma, chronic obstructive pulmonary disease, or heart failure in 2012, who had ≥2 consultations with these diagnoses during 2014 were included. CoC was measured during 2014 by using the usual provider of care (UPC) index and Bice-Boxerman continuity of care score (COCI). Both indices have a value between 0 and 1. RESULTS Patients with diabetes mellitus comprised the largest study population (N = 79,165) and heart failure the smallest (N = 4,122). The highest mean UPC and COCI were measured for patients with heart failure, 0.75 and 0.77, respectively. UPC increased gradually with age for all diagnoses, while COCI showed this trend only for asthma. Both indices had higher values in urban areas. CONCLUSIONS Our findings suggest that CoC in Norwegian healthcare system is achieved for a majority of patients with chronic diseases. Patients with heart failure had the highest continuity with their RGP. Higher CoC was associated with older age and living in urban areas.
Collapse
Affiliation(s)
- Sahar Pahlavanyali
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jesper Blinkenberg
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| |
Collapse
|
16
|
Nystøyl DS, Østerås Ø, Hunskaar S, Zakariassen E. Acute medical missions by helicopter medical service (HEMS) to municipalities with different approach for primary care physicians. BMC Emerg Med 2022; 22:102. [PMID: 35676626 PMCID: PMC9178819 DOI: 10.1186/s12873-022-00655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 05/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background The prehospital emergency system in Norway involves out-of-hours (OOH) services with on-call physicians. Helicopter emergency medical service (HEMS) are used in cases of severe illness or trauma that require rapid transport and/or an anesthesiologist’s services. In recent years, on-call primary care physicians have been less available for call-outs in Norway, and HEMS may be requested for missions that could be adequately handled by on-call physicians. Here, we investigated how different availability of an on-call physician to attend emergency patients at site (call-out) impacted requests and use of HEMS. Methods Our analysis included all acute medical missions in an urban and nearby rural OOH district, which had different approach regarding physician call-outs from the OOH service. For this prospective observational study, we used data from both HEMS and the OOH service from November 1st 2017 until November 30th 2018. Standard descriptive statistical analyses were used. Results The rates of acute medical missions in the urban and rural OOH districts were similar (30 and 29 per 1000 inhabitants per year, respectively). The rate of HEMS requests was significantly higher in the rural OOH district than in the urban district (2.4 vs. 1.7 per 1000 inhabitants per year, respectively). Cardiac arrest and trauma were the major symptom categories in more than one half of the HEMS-attended patients, in both districts. Chest pain was the most frequent reason for an OOH call-out in the rural OOH district (21.1%). An estimated NACA score of 5–7 was found in 47.7% of HEMS patients from the urban district, in 40.0% of HEMS patients from the rural OOH district (p = 0.44), and 12.8% of patients attended by an on-call physician in the rural OOH district (p < 0.001). Advanced interventions were provided by an anesthesiologist to one-third of the patients attended by HEMS, of whom a majority had an NACA score of ≥ 5. Conclusions HEMS use did not differ between the two compared areas, but the rate of HEMS requests was significantly higher in the rural OOH district. The threshold for HEMS use seems to be independent of on-call primary care physician involvement.
Collapse
Affiliation(s)
- Dag Ståle Nystøyl
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway. .,Department of Global Public Health and Primary Care, Group for Health Services Research, University of Bergen, Bergen, Norway.
| | - Øyvind Østerås
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, Group for Health Services Research, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Erik Zakariassen
- Department of Global Public Health and Primary Care, Group for Health Services Research, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| |
Collapse
|
17
|
Svedahl ER, Pape K, Austad B, Vie GÅ, Anthun KS, Carlsen F, Bjørngaard JH. Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts. Fam Pract 2022; 39:381-388. [PMID: 34694363 PMCID: PMC9155163 DOI: 10.1093/fampra/cmab120] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use. OBJECTIVE To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety. METHODS This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design. RESULTS Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death. CONCLUSIONS GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.
Collapse
Affiliation(s)
- Ellen Rabben Svedahl
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristine Pape
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjarne Austad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnhild Åberge Vie
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjartan Sarheim Anthun
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Health Research, SINTEF Digital, Trondheim, Norway
| | - Fredrik Carlsen
- Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
| |
Collapse
|
18
|
Glette MK, Kringeland T, Røise O, Wiig S. Helsepersonells erfaringer med reinnleggelser fra primærhelsetjenesten – en oppsummering av en casestudie. TIDSSKRIFT FOR OMSORGSFORSKNING 2022. [DOI: 10.18261/tfo.8.1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
19
|
Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. Br J Gen Pract 2022; 72:e84-e90. [PMID: 34607797 PMCID: PMC8510690 DOI: 10.3399/bjgp.2021.0340] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/20/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere. AIM To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality. DESIGN AND SETTING Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs. METHOD Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses. RESULTS Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years. CONCLUSION Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.
Collapse
Affiliation(s)
- Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen
| | - Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen; Department of Global Public Health and Primary Care, University of Bergen, Bergen
| | - Steinar Hunskaar
- NORCE Norwegian Research Centre, Bergen; Department of Global Public Health and Primary Care, University of Bergen, Bergen
| |
Collapse
|
20
|
Blinkenberg J, Hetlevik Ø, Sandvik H, Baste V, Hunskaar S. Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study. BMC Health Serv Res 2022; 22:78. [PMID: 35033069 PMCID: PMC8761320 DOI: 10.1186/s12913-021-07444-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral. Methods A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR. Results Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men. Conclusions The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.
Collapse
Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009, Bergen, Norway.
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009, Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Årstadveien 17, 5009, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 17, 5009, Bergen, Norway
| |
Collapse
|
21
|
Volpato L, Del Río Carral M, Senn N, Santiago Delefosse M. General Practitioners' Perceptions of the Use of Wearable Electronic Health Monitoring Devices: Qualitative Analysis of Risks and Benefits. JMIR Mhealth Uhealth 2021; 9:e23896. [PMID: 34383684 PMCID: PMC8386401 DOI: 10.2196/23896] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/15/2021] [Accepted: 05/17/2021] [Indexed: 01/13/2023] Open
Abstract
Background The rapid diffusion of wearable electronic health monitoring devices (wearable devices or wearables) among lay populations shows that self-tracking and self-monitoring are pervasively expanding, while influencing health-related practices. General practitioners are confronted with this phenomenon, since they often are the expert-voice that patients will seek. Objective This article aims to explore general practitioners’ perceptions of the role of wearable devices in family medicine and of their benefits, risks, and challenges associated with their use. It also explores their perceptions of the future development of these devices. Methods Data were collected during a medical conference among 19 Swiss general practitioners through mind maps. Maps were first sketched at the conference and their content was later compared with notes and reports written during the conference, which allowed for further integration of information. This tool represents an innovative methodology in qualitative research that allows for time-efficient data collection and data analysis. Results Data analysis highlighted that wearable devices were described as user-friendly, adaptable devices that could enable performance monitoring and support medical research. Benefits included support for patients’ empowerment and education, behavior change facilitation, better awareness of personal medical history and body functioning, efficient information transmission, and connection with the patient’s medical network; however, general practitioners were concerned by a lack of scientific validation, lack of clarity over data protection, and the risk of stakeholder-associated financial interests. Other perceived risks included the promotion of an overly medicalized health culture and the risk of supporting patients’ self-diagnosis and self-medication. General practitioners also feared increased pressure on their workload and a compromised doctor–patient relationship. Finally, they raised important questions that can guide wearables’ future design and development, highlighting a need for general practitioners and medical professionals to be involved in the process. Conclusions Wearables play an increasingly central role in daily health-related practices, and general practitioners expressed a desire to become more involved in the development of such technologies. Described as useful information providers, wearables were generally positively perceived and did not seem to pose a threat to the doctor–patient relationship. However, general practitioners expressed their concern that wearables may fuel a self-monitoring logic, to the detriment of patients’ autonomy and overall well-being. While wearables can contribute to health promotion, it is crucial to clarify the logic underpinning the design of such devices. Through the analysis of group discussions, this study contributes to the existing literature by presenting general practitioners’ perceptions of wearable devices. This paper provides insight on general practitioners’ perception to be considered in the context of product development and marketing.
Collapse
Affiliation(s)
- Lucia Volpato
- Research Centre for Psychology of Health, Aging and Sport Examination, Institute of Psychology, University of Lausanne, Lausanne, Switzerland
| | - María Del Río Carral
- Research Centre for Psychology of Health, Aging and Sport Examination, Institute of Psychology, University of Lausanne, Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Marie Santiago Delefosse
- Research Centre for Psychology of Health, Aging and Sport Examination, Institute of Psychology, University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
22
|
Nystrøm V, Lurås H, Midlöv P, Leonardsen ACL. What if something happens tonight? A qualitative study of primary care physicians' perspectives on an alternative to hospital admittance. BMC Health Serv Res 2021; 21:447. [PMID: 33975573 PMCID: PMC8112060 DOI: 10.1186/s12913-021-06444-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/26/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians' (PCPs') perspectives on admission to a MAW as an alternative to hospitalisation. METHODS The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach. RESULTS The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients' condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients' and relatives' participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients' wishes conflicted with what PCPs considered professionally sound. CONCLUSIONS The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.
Collapse
Affiliation(s)
- Vivian Nystrøm
- Department of Health and Welfare, Østfold University College, (PB) 700, 1757 Halden, Norway
| | - Hilde Lurås
- Health Services Research Unit, Akershus University Hospital, (PB) 1000, 1478 Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lørenskog, Norway
| | - Patrik Midlöv
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, (PB) 50332, 202 13 Malmö, Sweden
| | - Ann-Chatrin Linqvist Leonardsen
- Department of Health and Welfare, Østfold University College, (PB) 700, 1757 Halden, Norway
- Østfold Hospital Trust, Halden, Norway
| |
Collapse
|
23
|
Johannessen TR, Vallersnes OM, Halvorsen S, Larstorp ACK, Mdala I, Atar D. Pre-hospital One-Hour Troponin in a Low-Prevalence Population of Acute Coronary Syndrome: OUT-ACS study. Open Heart 2020; 7:openhrt-2020-001296. [PMID: 32719074 PMCID: PMC7380862 DOI: 10.1136/openhrt-2020-001296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/08/2020] [Accepted: 05/26/2020] [Indexed: 02/03/2023] Open
Abstract
Objective The European Society of Cardiology 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) has demonstrated high rule-out safety in large hospital validation cohorts. We aimed to validate the algorithm in a primary care setting, where patients have a lower pretest probability for acute coronary syndrome. Methods This prospective, observational, diagnostic study included patients with acute non-specific chest pain admitted to a primary care emergency clinic in Oslo, Norway, from November 2016 to October 2018. hs-cTnT was measured after 0, 1 and 4 hours. The primary outcome measure was the diagnostic performance of the 0/1-hour algorithm, the 90-day incidence of AMI or all-cause death the secondary. Results Among 1711 included patients, 61 (3.6%) were diagnosed with AMI. By applying the algorithm, 1311 (76.6%) patients were assigned to the rule-out group. The negative predictive value was 99.9% (95% CI 99.5% to 100.0%), the sensitivity and specificity 98.4% (91.2–100.0) and 79.4% (77.4–81.3), respectively. Sixty-six (3.9%) patients were triaged towards rule-in, where 45 were diagnosed with AMI. The corresponding positive predictive value was 68.2% (58.3–76.7), sensitivity 73.8% (60.9–84.2), and specificity 98.7% (98.1–99.2). Among 334 (19.5%) patients assigned to the observation group in need of further tests, 15 patients had an AMI. The following 90 days, five new patients experienced an AMI and nine patients died, with a low incidence in the rule-out group (0.3%). Conclusion The 0/1-hour algorithm for hs-cTnT seems safe, efficient and applicable for an accelerated assessment of patients with non-specific chest pain in a primary care emergency setting. Trial registration number NCT02983123.
Collapse
Affiliation(s)
- Tonje R Johannessen
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway .,Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Services, Oslo, Norway
| | - Odd Martin Vallersnes
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.,Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Services, Oslo, Norway
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Cecilie K Larstorp
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Medical Biochemistry, Section of Cardiovascular and Renal Reseach, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Ibrahimu Mdala
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
24
|
Husabø G, Nilsen RM, Solligård E, Flaatten HK, Walshe K, Frich JC, Bondevik GT, Braut GS, Helgeland J, Harthug S, Hovlid E. Effects of external inspections on sepsis detection and treatment: a stepped-wedge study with cluster-level randomisation. BMJ Open 2020; 10:e037715. [PMID: 33082187 PMCID: PMC7577024 DOI: 10.1136/bmjopen-2020-037715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To evaluate the effects of external inspections on (1) hospital emergency departments' clinical processes for detecting and treating sepsis and (2) length of hospital stay and 30-day mortality. DESIGN Incomplete cluster-randomised stepped-wedge design using data from patient records and patient registries. We compared care processes and patient outcomes before and after the intervention using regression analysis. SETTING Nationwide inspections of sepsis care in emergency departments in Norwegian hospitals. PARTICIPANTS 7407 patients presenting to hospital emergency departments with sepsis. INTERVENTION External inspections of sepsis detection and treatment led by a public supervisory institution. MAIN OUTCOME MEASURES Process measures for sepsis diagnostics and treatment, length of hospital stay and 30-day all-cause mortality. RESULTS After the inspections, there were significant improvements in the proportions of patients examined by a physician within the time frame set in triage (OR 1.28, 95% CI 1.07 to 1.53), undergoing a complete set of vital measurements within 1 hour (OR 1.78, 95% CI 1.10 to 2.87), having lactate measured within 1 hour (OR 2.75, 95% CI 1.83 to 4.15), having an adequate observation regimen (OR 2.20, 95% CI 1.51 to 3.20) and receiving antibiotics within 1 hour (OR 2.16, 95% CI 1.83 to 2.55). There was also significant reduction in mortality and length of stay, but these findings were no longer significant when controlling for time. CONCLUSIONS External inspections were associated with improvement of sepsis detection and treatment. These findings suggest that policy-makers and regulatory agencies should prioritise assessing the effects of their inspections and pay attention to the mechanisms by which the inspections might contribute to improve care for patients. TRIAL REGISTRATION NCT02747121.
Collapse
Affiliation(s)
- Gunnar Husabø
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Roy Miodini Nilsen
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Erik Solligård
- Clinic of Anesthesia and Intensive Care, St. Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Kieran Walshe
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Jan C Frich
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Gunnar Tschudi Bondevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
| | - Geir Sverre Braut
- Department of Research, Stavanger University Hospital, Stavanger, Norway
- Department 5, Norwegian Board of Health Supervision, Oslo, Norway
| | | | - Stig Harthug
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Einar Hovlid
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department 5, Norwegian Board of Health Supervision, Oslo, Norway
| |
Collapse
|
25
|
Blinkenberg J, Pahlavanyali S, Hetlevik Ø, Sandvik H, Hunskaar S. Correction to: General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study. BMC Health Serv Res 2020; 20:876. [PMID: 32938473 PMCID: PMC7493318 DOI: 10.1186/s12913-020-05590-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway.
| | - Sahar Pahlavanyali
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| |
Collapse
|
26
|
Søvsø MB, Huibers L, Bech BH, Christensen HC, Christensen MB, Christensen EF. Acute care pathways for patients calling the out-of-hours services. BMC Health Serv Res 2020; 20:146. [PMID: 32106846 PMCID: PMC7045402 DOI: 10.1186/s12913-020-4994-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In Western countries, patients with acute illness or injury out-of-hours (OOH) can call either emergency medical services (EMS) for emergencies or primary care services (OOH-PC) in less urgent situations. Callers initially choose which service to contact; whether this choice reflect the intended differences in urgency and severity is unknown. Hospital diagnoses and admission rates following an OOH service contact could elucidate this. We aimed to investigate and compare the prevalence of patient contacts, subsequent hospital contacts, and the age-related pattern of hospital diagnoses following an out-of-hours contact to EMS or OOH-PC services in Denmark. METHODS Population-based observational cohort study including patients from two Danish regions with contact to EMS or OOH-PC in 2016. Hospital contacts were defined as short (< 24 h) or admissions (≥24 h) on the date of OOH service contact. Both regions have EMS, whereas the North Denmark Region has a general practitioner cooperative (GPC) as OOH-PC service and the Capital Region of Copenhagen the Medical Helpline 1813 (MH-1813), together representing all Danish OOH service types. Calling an OOH service is mandatory prior to a hospital contact outside office hours. RESULTS OOH-PC handled 91% (1,107,297) of all contacts (1,219,963). Subsequent hospital contacts were most frequent for EMS contacts (46-54%) followed by MH-1813 (41%) and GPC contacts (9%). EMS had more admissions (52-56%) than OOH-PC. For both EMS and OOH-PC, short hospital contacts often concerned injuries (32-63%) and non-specific diagnoses (20-45%). The proportion of circulatory disease was almost twice as large following EMS (13-17%) compared to OOH-PC (7-9%) in admitted patients, whereas respiratory diseases (11-14%), injuries (15-22%) and non-specific symptoms (22-29%) were more equally distributed. Generally, admitted patients were older. CONCLUSIONS EMS contacts were fewer, but with a higher percentage of hospital contacts, admissions and prevalence of circulatory diseases compared to OOH-PC, perhaps indicating that patients more often contact EMS in case of severe disease. However, hospital diagnoses only elucidate severity of diseases to some extent, and other measures of severity could be considered in future studies. Moreover, the socio-demographic pattern of patients calling OOH needs exploration as this may play an important role in choice of entrance.
Collapse
Affiliation(s)
- Morten Breinholt Søvsø
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
| | | | | | - Erika Frischknecht Christensen
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| |
Collapse
|