[Travel distance and the utilisation of out-of-hours services]

Experiences of patients with complex needs at municipal emergency outpost satellites

BACKGROUND

In 2015, Norway introduced stricter requirements for organizing primary emergency care. These changes led to new solutions such as municipal emergency outpost satellites, providing inhabitants shorter access to care in resource-limited areas. This study explores patient experiences at emergency outpost satellites staffed by a nurse on site with a general practitioner (GP) available via video consultation.

METHODS

A qualitative study was conducted with seven patients, aged 62-82, with complex needs, from four small and medium-sized municipalities in Vestland County, Norway. Data were collected through individual semi-structured interviews, which took place within 6 months of an acute consultation at an emergency outpost satellite. The data were analysed using systematic text condensation (STC).

RESULTS

Patients had both positive and negative experiences with video consultations. They valued short travel distances and quick GP access via video link. Video consultations often replicated several aspects of in-person visits, with nurses playing a crucial role in organizing and ensuring that care was provided effectively. Nurses were key mediators, supporting patients before, during, and after the consultation. However, some patients were dissatisfied with the lack of a physical GP presence, technical issues, and communication challenges.

CONCLUSIONS

The participants' experience of communication with the GP and nurse was crucial for the video consultation to be perceived as satisfactory. Participants felt that video consultations reduced travel burdens and provided quick clarification. Nurses played an important mediating role, but poor communication and technical issues made some participants feel unsafe using the emergency outpost satellites.

Use of primary health care services among children and adolescents with cerebral palsy

AIM

To investigate the use of general practitioners and urgent care centres (UCC) among children and adolescents with cerebral palsy (CP) compared to a control group, and per gross motor function level.

METHOD

Data on children with CP born 1996 to 2014 were collected from the Norwegian Quality and Surveillance Registry for Cerebral Palsy. A control group was extracted from Statistics Norway. The date and diagnosis codes for general practitioner and UCC contacts from 2006 to 2015 were collected from the Norwegian Control and Payment of Health Reimbursement Database. Incidence rate ratios (IRR) for the number of contacts per person-year with 95% confidence intervals (CI) were calculated using Poisson regression. Risk differences with 95% CI were used to compare cumulative diagnosis incidences between children with CP and the control group.

RESULTS

The study included 2510 children (1457 males; 58.1%) with CP and 12 041 (7003 males; 58.2%) without CP (mean age in both groups 7 years 2 months, SD 4 years 8 months, range 0-19 years), with 336 250 contacts. Children with CP had more general practitioner (IRR 1.47; 95% CI 1.29-1.67) and UCC (IRR 1.30; 95% CI 1.13-1.50) contacts than children without CP, for all ages. IRRs remained unchanged when comparing children with CP in Gross Motor Function Classification System (GMFCS) levels I and II to children without CP. Among children with CP, contact increased as GMFCS levels increased, and they were in contact most often for respiratory and general and unspecified diagnoses. The risk for epilepsy was highest for those in contact with general practitioners.

INTERPRETATION

Children with CP, including those with less severe motor impairments, contacted general practitioners and UCCs more than children without CP. However, contact increased as gross motor impairment increased. They had contact for many diagnoses, mostly respiratory.

How time consuming are general practitioners' home visits? Insights from a cross-sectional study in Switzerland

BACKGROUND

Worldwide, the number of home visits has been decreasing over past decades. Lack of time and long journeys have been reported to hinder general practitioners (GPs) from conducting home visits. In Switzerland also, home visits have declined. Time constraints in a busy GP practice could be one reason. Therefore, the aim of this study was to analyse the time requirements of home visits in Switzerland.

METHODS

A one-year cross-sectional study involving GPs from the Swiss Sentinel Surveillance System (Sentinella) was conducted in 2019. GPs provided basic information on all home visits performed throughout the year and additionally detailed reports of up to 20 consecutive home visits. Univariable and multivariable logistic regression analyses were run to identify factors affecting journey and consultation duration.

RESULTS

In total, 95 GPs conducted 8489 home visits in Switzerland, 1139 of which have been characterised in detail. On average, GPs made 3.4 home visits per week. Average journey and consultation duration were 11.8 and 23.9 minutes, respectively. Prolonged consultations were provided by GPs working part-time (25.1 minutes), in group practice (24.9 minutes) or in urban regions (24.7 minutes). Rural environments and short journey to patient's home were both found to lower the odds of performing a long consultation compared to a short consultation (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.16-0.44 and OR 0.60, 95% CI 0.46-0.77, respectively). Emergency visits (OR 2.20, 95% CI 1.21-4.01), out-of-hours appointments (OR 3.06, 95% CI 2.36-3.97) and day care involvement (OR 2.78, 95% CI 2.13-3.62) increased the odds of having a long consultation. Finally, patients in their 60s had markedly higher odds of receiving long consultations than patients in their 90s (OR 4.13, 95% CI 2.27-7.62), whereas lack of chronic conditions lowered the odds of a long consultation (OR 0.09, 95% CI 0.00-0.43).

CONCLUSION

GPs perform rather few but long home visits, especially for multimorbid patients. GPs working part-time, in group practice or in urban regions devote more time to home visits.

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

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.

Helicopter emergency medical service (HEMS) activity after increased distance to out-of-hours services: an observational study from Norway

Background

Organizational changes in out-of-hour (OOH) services may have unintended consequences for other prehospital services. Reports indicate an increased use of helicopter emergency medical services (HEMS) after changes in OOH services in Norway due to greater geographical distances for the on-call doctors. We investigated whether HEMS dispatches increased when nine municipalities in Sogn og Fjordane County merged into one large inter-municipal OOH district.

Methods

All primary dispatches of the HEMS in the county between 2004 and 2013 were included. We applied interrupted time series regression to monthly aggregated data to evaluate the impact of the organizational change 1 April 2009. The nine target municipalities were compared to the rest of the municipalities in the county, which served as a control group. A quasipoisson model adjusted for seasonality was found to be most applicable.

Results

We included 8,751 dispatches, 5,009 (57.2%) of which were completed with a patient encounter. Overall, we found no alteration in requests for HEMS after 2009 (p = 0.251). Separate analyses of the target municipalities and control group revealed no significant increase after 2009 (p = 0.400 and p = 0.056, respectively). When categorizing the municipalities into urban or rural, we found a general increase in HEMS dispatches for the rural group over the 10-year span (p = 0.045) but no added increase after 2009 (p = 0.502). The urban subgroup showed no change. Distance from the OOH service in regards to travel increased within the nine municipalities after 2009, median [quartiles] (5.0[3.0, 6.2] km vs 26.5[5.0, 62.2] km, p < 0.001).

Conclusion

After relocating nine local OOH services into one large inter-municipal OOH district, we found no increase in requests for HEMS.

Associations Between the Use of eHealth and Out-of-Hours Services in People With Type 1 Diabetes: Cross-Sectional Study

BACKGROUND

Despite the increasing prevalence of diabetes and the increasing use of eHealth, little is known about the association between provider-based health services and eHealth among people with diabetes. This is the second study in a project exploring the associations between the use of eHealth and the use of provider-based health services.

OBJECTIVE

The objective of this study was to investigate which eHealth services are used among out-of-hours (OOH) visitors with type 1 diabetes (T1D), and whether the use of eHealth (eg, apps, search engines, video services, and social media) was associated with the use of OOH services. We also wanted to investigate associations between anxiety, reassurance, and change in doctor-seeking behavior because of health information acquired from the Internet, and the use of OOH services.

METHODS

We used data from a 2018 email survey of members of the Norwegian Diabetes Association (18-89 years old). Respondents with T1D were eligible for analyses. Using descriptive statistics, we estimated the use of OOH services and eHealth. Using logistic regressions, we studied the associations between the use of OOH services and the use of eHealth, as well as associations between the use of OOH services and reported consequences of using Internet-based health information.

RESULTS

In the sample of 523 people with T1D (mean age 47 years), 26.7% (129/484) visited OOH services once or more during the previous year. Among the OOH visitors, search engines were used for health purposes by 86.7% (111/128), apps (health apps in general) by 63.6% (82/129), social media by 45.3% (58/128), and video services by 28.4% (36/127). The use of OOH services was positively associated with self-reported anxiety/depression (odds ratio [OR] 4.53, 95% CI 1.43-14.32) and with the use of apps (OR 1.73, 95% CI 1.05-2.85), but not with other types of eHealth. Those who had felt anxious based on information from the Internet were more likely to visit OOH services compared with those who had not felt anxious (OR 2.38, 95% CI 1.50-3.78). People who had decided to consult a doctor based on information from the Internet were more likely to visit OOH services (OR 2.76, 95% CI 1.64-4.66), compared to those who had not made such an Internet-based decision.

CONCLUSIONS

People with T1D were frequent users of OOH services, and the OOH visitors were frequent users of eHealth. The use of OOH services was positively associated with the use of health apps, with self-reported anxiety/depression, and with feeling anxious based on information from the Internet. Likewise, deciding to consult a doctor based on information from the Internet was positively associated with OOH visits. The use of eHealth seems to have a significant impact on people with T1D.

Geographic Variation in Antibiotic Consumption-Is It Due to Doctors' Prescribing or Patients' Consulting?

Antibiotic consumption varies greatly between Norwegian municipalities. We examine whether this variation is associated with inhabitants' consultation rates or general practitioners' (GP) prescription rates. Our study comprises consultations and antibiotic prescriptions for respiratory tract infections (RTIs) in general practice in all Norwegian municipalities with over 5000 inhabitants in 2014. Data was collected from The Norwegian Prescription Database, The Directorate of Health's system for control and payment of health reimbursements registry and Norway Statistics. Consultation rates and prescription rates were categorised in age- and gender specific quintiles and the effect on antibiotic consumption was analysed using a Poisson regression model. We found that inhabitants with RTIs received 42% more prescriptions if they belonged to a municipality with high consultation rates compared to low consultation rates [incidence rate ratio (IRR) 1.42 (95% CI 1.41-1.44)] and 48% more prescriptions if they belonged to a municipality with high prescription rates versus low prescription rates [IRR 1.48 (95% KI 1.47-1.50)]. Our results demonstrate that inhabitants' consultation rates and GPs' prescription rates have about equal impact on the number of RTI antibiotics prescribed at municipality level. These findings highlight the importance of interventions targeting patients as well as doctors in efforts to reduce unnecessary antibiotic consumption.