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Johansson T, Chambers RL, Curtis T, Pask S, Greenley S, Brittain M, Bone AE, Laidlaw L, Okamoto I, Barclay S, Higginson IJ, Murtagh FEM, Sleeman KE. The effectiveness of out-of-hours palliative care telephone advice lines: A rapid systematic review. Palliat Med 2024:2692163241248544. [PMID: 38708864 DOI: 10.1177/02692163241248544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
BACKGROUND People with palliative care needs and their carers often rely on out-of-hours services to remain at home. Policymakers have recommended implementing telephone advice lines to ensure 24/7 access to support. However, the impact of these services on patient and carer outcomes, as well as the health care system, remains poorly understood. AIM To evaluate the clinical- and cost-effectiveness of out-of-hours palliative care telephone advice lines, and to identify service characteristics associated with effectiveness. DESIGN Rapid systematic review (PROSPERO ID: CRD42023400370) with narrative synthesis. DATA SOURCES Three databases (Medline, EMBASE and CINAHL) were searched in February 2023 for studies of any design reporting on telephone advice lines with at least partial out-of-hours availability. Study quality was assessed using the Mixed Methods Appraisal Tool, and quantitative and qualitative data were synthesised narratively. RESULTS Twenty-one studies, published 2000-2022, were included. Most studies were observational, none were experimental. While some evidence suggested that telephone advice lines offer guidance and reassurance, supporting care at home and potentially reducing avoidable emergency care use in the last months of life, variability in reporting and poor methodological quality across studies limit our understanding of patient/carer and health care system outcomes. CONCLUSION Despite their increasing use, evidence for the clinical- and cost-effectiveness of palliative care telephone advice lines remains limited, primarily due to the lack of robust comparative studies. There is a need for more rigorous evaluations incorporating experimental or quasi-experimental methods and longer follow-up, and standardised reporting of telephone advice line models and outcomes, to guide policy and practice.
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Affiliation(s)
- Therese Johansson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Rachel L Chambers
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Thomas Curtis
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Sophie Pask
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sarah Greenley
- Institute of Clinical and Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | - Molly Brittain
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Anna E Bone
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Lynn Laidlaw
- Cicely Saunders Institute Patient & Public Involvement Group, King's College London, London, UK
| | - Ikumi Okamoto
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Fliss E M Murtagh
- Institute of Clinical and Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
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Nebsbjerg MA, Vestergaard CH, Bomholt KB, Christensen MB, Huibers L. Use of Video in Telephone Triage in Out-of-Hours Primary Care: Register-Based Study. JMIR Med Inform 2024; 12:e47039. [PMID: 38596835 PMCID: PMC11007381 DOI: 10.2196/47039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 04/11/2024] Open
Abstract
Background Out-of-hours primary care (OOH-PC) is challenging due to high workloads, workforce shortages, and long waiting and transportation times for patients. Use of video enables triage professionals to visually assess patients, potentially ending more contacts in a telephone triage contact instead of referring patients to more resource-demanding clinic consultations or home visits. Thus, video use may help reduce use of health care resources in OOH-PC. Objective This study aimed to investigate video use in telephone triage contacts to OOH-PC in Denmark by studying rate of use and potential associations between video use and patient- and contact-related characteristics and between video use and triage outcomes and follow-up contacts. We hypothesized that video use could serve to reduce use of health care resources in OOH-PC. Methods This register-based study included all telephone triage contacts to OOH-PC in 4 of the 5 Danish regions from March 15, 2020, to December 1, 2021. We linked data from the OOH-PC electronic registration systems to national registers and identified telephone triage contacts with video use (video contact) and without video use (telephone contact). Calculating crude incidence rate ratios and adjusted incidence rate ratios (aIRRs), we investigated the association between patient- and contact-related characteristics and video contacts and measured the frequency of different triage outcomes and follow-up contacts after video contact compared to telephone contact. Results Of 2,900,566 identified telephone triage contacts to OOH-PC, 9.5% (n=275,203) were conducted as video contacts. The frequency of video contact was unevenly distributed across patient- and contact-related characteristics; it was used more often for employed young patients without comorbidities who contacted OOH-PC more than 4 hours before the opening hours of daytime general practice. Compared to telephone contacts, notably more video contacts ended with advice and self-care (aIRR 1.21, 95% CI 1.21-1.21) and no follow-up contact (aIRR 1.08, 95% CI 1.08-1.09). Conclusions This study supports our hypothesis that video contacts could reduce use of health care resources in OOH-PC. Video use lowered the frequency of referrals to a clinic consultation or a home visit and also lowered the frequency of follow-up contacts. However, the results could be biased due to confounding by indication, reflecting that triage GPs use video for a specific set of reasons for encounters.
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Affiliation(s)
| | | | | | - Morten Bondo Christensen
- Research Unit for General Practice, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus C, Denmark
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Shapera E, Touadi M, Dickow J, Azure E, Attar M, Gorges M, Aivaz M. Robotic Cholecystectomy Remains Safe and Effective After Regular Staffing Hours. Cureus 2024; 16:e54413. [PMID: 38505428 PMCID: PMC10950418 DOI: 10.7759/cureus.54413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/21/2024] Open
Abstract
Background Robotic-assisted surgery continues to grow in popularity. Access during evenings and weekends for non-elective operations can be restricted out of safety concerns. We sought to analyze and compare outcomes of patients undergoing robotic cholecystectomy, a common urgent procedure for acute calculous cholecystitis, during regular hours versus evenings or weekends. Based on this comparison, we sought to determine if this restriction is justified. Methods We performed a retrospective analysis of 46 patients who underwent robotic cholecystectomy for acute calculous cholecystitis per 2018 Tokyo criteria by a single surgeon at a single institution between 2021 and 2022. Patients were grouped as undergoing "after-hours" cholecystectomy if the operation started at five pm or later, or anytime during the weekend (Saturday, Sunday). Demographic, perioperative, and outcome variables were tabulated and analyzed. For illustrative purposes, the data presented as median ± standard deviation were applicable. Results After-hours cholecystectomy occurred in 26 patients and regular-hours cholecystectomy occurred in 20 patients. There were no significant differences in perioperative variables between the two cohorts in terms of body mass index, age, gender, cirrhotic status, American Society of Anesthesiology score, white blood cell count, or neutrophil percentage. The after-hours group had more prior abdominal operations. There were no significant differences between the two groups in terms of operative time, estimated blood loss, or length of stay. There were no mortalities. There was one readmission in the after-hours cohort unrelated to the operation. Conclusion Robotic cholecystectomy can be safely performed on the weekends and evenings. Hospitals should make the robotic platform available during this time.
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Affiliation(s)
| | - Melissa Touadi
- School of Medicine, University of South Florida, Tampa, USA
| | - Jade Dickow
- Surgery, Academy of Our Lady of Peace, San Diego, USA
| | - Ellie Azure
- Surgery, Academy of Our Lady of Peace, San Diego, USA
| | - Melania Attar
- Surgery, Academy of Our Lady of Peace, San Diego, USA
| | - Melinda Gorges
- Surgery, University of California San Diego, San Diego, USA
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Walshe C, Mateus C, Varey S, Dodd S, Cockshott Z, Filipe L, Brearley SG. 'Thank goodness you're here'. Exploring the impact on patients, family carers and staff of enhanced 7-day specialist palliative care services: A mixed methods study. Palliat Med 2023; 37:1484-1497. [PMID: 37731382 PMCID: PMC10657500 DOI: 10.1177/02692163231201486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND Healthcare usage patterns change for people with life limiting illness as death approaches, with increasing use of out-of-hours services. How best to provide care out of hours is unclear. AIM To evaluate the effectiveness and effect of enhancements to 7-day specialist palliative care services, and to explore a range of perspectives on these enhanced services. DESIGN An exploratory longitudinal mixed-methods convergent design. This incorporated a quasi-experimental uncontrolled pre-post study using routine data, followed by semi-structured interviews with patients, family carers and health care professionals. SETTING/PARTICIPANTS Data were collected within specialist palliative care services across two UK localities between 2018 and 2020. Routine data from 5601 unique individuals were analysed, with post-intervention interview data from patients (n = 19), family carers (n = 23) and health care professionals (n = 33; n = 33 time 1, n = 20 time 2). RESULTS The mean age of people receiving care was 73 years, predominantly white (90%) and with cancer (42%). There were trends for those in the intervention (enhanced care) period to stay in hospital 0.16 days fewer, but be hospitalised 2.67 more times. Females stayed almost 3.5 more days in the hospital, but were admitted 2.48 fewer times. People with cancer had shorter hospitalisations (4 days fewer), and had two fewer admission episodes. Themes from the qualitative data included responsiveness (of the service); reassurance; relationships; reciprocity (between patients, family carers and staff) and retention (of service staff). CONCLUSIONS Enhanced seven-day services provide high quality integrated palliative care, with positive experiences for patients, carers and staff.
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Affiliation(s)
- Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, England, UK
| | - Céu Mateus
- Health Economics at Lancaster, Division of Health Research, Lancaster University, Lancaster, England, UK
| | - Sandra Varey
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, England, UK
| | - Steven Dodd
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, England, UK
| | - Zoe Cockshott
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, England, UK
| | - Luís Filipe
- Health Economics at Lancaster, Division of Health Research, Lancaster University, Lancaster, England, UK
| | - Sarah G Brearley
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, England, UK
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McCracken MA, Cooper IR, Hamilton MA, Klimas J, Lindsay C, Fletcher S, Price M, Hedden L, McCracken RK. Access to episodic primary care: a cross-sectional comparison of walk-in clinics and urgent primary care centers in British Columbia. Prim Health Care Res Dev 2023; 24:e66. [PMID: 38014436 PMCID: PMC10689093 DOI: 10.1017/s1463423623000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/13/2023] [Accepted: 10/02/2023] [Indexed: 11/29/2023] Open
Abstract
AIM This study aimed to identify publicly reported access characteristics for episodic primary care in BC and provided a clinic-level comparison between walk-in clinics and UPCCs. BACKGROUND Walk-in clinics are non-hospital-based primary care facilities that are designed to operate without appointments and provide increased healthcare access with extended hours. Urgent and Primary Care Centres (UPCCs) were introduced to British Columbia (BC) in 2018 as an additional primary care resource that provided urgent, but not emergent care during extended hours. METHODS This cross-sectional study used publicly available data from all walk-in clinics and UPCCs in BC. A structured data collection form was used to record access characteristics from clinic websites, including business hours, weekend availability, attachment to a longitudinal family practice, and provision of virtual services. FINDINGS In total, 268 clinics were included in the analysis (243 walk-in clinics, 25 UPCCs). Of those, 225 walk-in clinics (92.6%) and two UPCCs (8.0%) were attached to a longitudinal family practice. Only 153 (63%) walk-in clinics offered weekend services, compared to 24 (96%) of UPCCs. Walk-in clinics offered the majority (8,968.6/ 78.4%) of their service hours between 08:00 and 17:00, Monday to Friday. UPCCs offered the majority (889.3/ 53.7%) of their service hours after 17:00. CONCLUSION Most walk-in clinics were associated with a longitudinal family practice and provided the majority of clinic services during typical business hours. More research that includes patient characteristics and care outcomes, analyzed at the clinic level, may be useful to support the optimization of episodic primary healthcare delivery.
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Affiliation(s)
- Mary A. McCracken
- Innovation Support Unit, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Ian R. Cooper
- Innovation Support Unit, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michee-Ana Hamilton
- Innovation Support Unit, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jan Klimas
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Cameron Lindsay
- Innovation Support Unit, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sarah Fletcher
- Innovation Support Unit, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Morgan Price
- Innovation Support Unit, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay Hedden
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, V6T 2A1, Canada
| | - Rita K. McCracken
- Innovation Support Unit, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
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Cazacu SM, Turcu-Stiolica A, Florescu DN, Ungureanu BS, Iovanescu VF, Neagoe CD, Burtea DE, Genunche-Dumitrescu AV, Avramescu TE, Iordache S. The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period. J Multidiscip Healthc 2023; 16:3151-3165. [PMID: 37908341 PMCID: PMC10615097 DOI: 10.2147/jmdh.s427449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023] Open
Abstract
Background In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality. Aim To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic. Methods We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days. Results 802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups. Conclusion Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.
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Affiliation(s)
- Sergiu Marian Cazacu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Adina Turcu-Stiolica
- Biostatistics Department, University of Medicine and Pharmacy Craiova, Dolj County, Romania
| | - Dan Nicolae Florescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Bogdan Silviu Ungureanu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Vlad Florin Iovanescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Carmen Daniela Neagoe
- Internal Medicine Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Daniela Elena Burtea
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | | | - Taina Elena Avramescu
- Individual Sports, and Medical Disciplines Departments, University of Craiova, Dolj County, Romania
| | - Sevastita Iordache
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
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Turnock A, Fielding A, Moad D, Tapley A, Davey A, Holliday E, Ball J, Bentley M, FitzGerald K, Kirby C, Spike N, van Driel ML, Magin P. The prevalence and associations of Australian early-career general practitioners' provision of after-hours care. Aust J Rural Health 2023; 31:906-913. [PMID: 37488936 DOI: 10.1111/ajr.13022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Access to after-hours care (AHC) is an important aspect of general practice service provision. OBJECTIVE To establish the prevalence and associations of early-career GPs' provision of AHC. DESIGN An analysis of data from the New alumni Experiences of Training and independent Unsupervised Practice (NEXT-UP) cross-sectional questionnaire-based study. Participants were early-career GPs (6-month to 2-year post-Fellowship) following the completion of GP vocational training in NSW, the ACT, Victoria or Tasmania. The outcome factor was 'current provision of after-hours care'. Associations of the outcome were established using multivariable logistic regression. FINDINGS Three hundred and fifty-four early-career GPs participated (response rate 28%). Of these, 322 had responses available for analysis of currently performing AHC. Of these observations, 128 (40%) reported current provision of AHC (55% of rural participants and 32% of urban participants). On multivariable analysis, participants who provided any AHC during training were more likely to be providing AHC (odds ratio (OR) 5.51, [95% confidence interval (CI) 2.80-10.80], p < 0.001). Current rural location and in-training rural experience were strongly associated with currently providing AHC in univariable but not multivariable analysis. DISCUSSION Early-career GPs who provided AHC during training, compared with those who did not, were more than five times more likely to provide after-hours care in their first 2 years after gaining Fellowship, suggesting participation in AHC during training may have a role in preparing registrars to provide AHC as independent practitioners. CONCLUSION These findings may inform future GP vocational training policy and practice concerning registrars' provision of AHC during training.
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Affiliation(s)
- Allison Turnock
- University of Tasmania, School of Medicine, Hobart, Tasmania, Australia
- Department of Health, Hobart, Tasmania, Australia
| | - Alison Fielding
- GP Synergy, NSW & ACT Research and Evaluation Unit, Mayfield West, New South Wales, Australia
- The University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, New South Wales, Australia
| | - Dominica Moad
- GP Synergy, NSW & ACT Research and Evaluation Unit, Mayfield West, New South Wales, Australia
- The University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, New South Wales, Australia
| | - Amanda Tapley
- GP Synergy, NSW & ACT Research and Evaluation Unit, Mayfield West, New South Wales, Australia
- The University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, New South Wales, Australia
| | - Andrew Davey
- GP Synergy, NSW & ACT Research and Evaluation Unit, Mayfield West, New South Wales, Australia
- The University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, New South Wales, Australia
| | - Elizabeth Holliday
- The University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, New South Wales, Australia
| | - Jean Ball
- Hunter Medical Research Institute (HMRI), Clinical Research Design and Statistical Support Unit (CReDITSS), New Lambton Heights, New South Wales, Australia
| | - Michael Bentley
- General Practice Training Tasmania (GPTT), Hobart, Tasmania, Australia
| | - Kristen FitzGerald
- University of Tasmania, School of Medicine, Hobart, Tasmania, Australia
- General Practice Training Tasmania (GPTT), Hobart, Tasmania, Australia
| | - Catherine Kirby
- Eastern Victoria General Practice Training (EVGPT), Hawthorn, Victoria, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training (EVGPT), Hawthorn, Victoria, Australia
- Monash University, School of Rural Health, Churchill, Victoria, Australia
- Department of General Practice and Primary Health Care, University of Melbourne, Carlton, Victoria, Australia
| | - Mieke L van Driel
- Faculty of Medicine, General Practice Clinical Unit, The University of Queensland, Brisbane, Queensland, Australia
| | - Parker Magin
- GP Synergy, NSW & ACT Research and Evaluation Unit, Mayfield West, New South Wales, Australia
- The University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, New South Wales, Australia
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Patynowska KA, McConnell T, McAtamney C, Hasson F. 'That just doesn't feel right at times' - lone working practices, support and educational needs of newly employed Healthcare Assistants providing 24/7 palliative care in the community: A qualitative interview study. Palliat Med 2023; 37:1183-1192. [PMID: 37334445 PMCID: PMC10503246 DOI: 10.1177/02692163231175990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
BACKGROUND Healthcare assistants working in hospice at home settings have a pivotal role in supporting people dying at home and their family caregivers. Some healthcare assistants are working alone in patients' homes, which magnifies some of the issues reported for those working closely with other team members. There is a dearth of evidence in terms of education, training and support needs for healthcare assistants when working alone. AIM To explore the role of newly employed lone working healthcare assistants delivering palliative care in the community, and their support and educational needs. DESIGN Qualitative exploratory study using semi-structured interviews. SETTING/PARTICIPANTS Healthcare assistants (n = 16) employed less than 12 months by a national non-profit hospice and palliative care provider located across the UK. RESULTS Analysis of interviews identified three main themes: (1) Healthcare assistants have a unique and complex role catering for holistic needs of patients and their family caregivers in the home environment; (2) preparation for the complex role requires focus on experiential learning and specific training to support holistic care provision; (3) lone workers experience loneliness and isolation and identify peer support as a key intervention to support their wellbeing. CONCLUSIONS Given the complexities of their role within community palliative care teams, there are key learning points in relation to healthcare assistant preparation. Education and support networks should be prioritised to reduce isolation and support ongoing learning and development of newly employed healthcare assistants; all of which is vital to ensure safety and quality of care for the growing number of people they support in the community.
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Affiliation(s)
| | - Tracey McConnell
- Marie Curie Hospice Belfast, Belfast, UK
- School of Nursing and Midwifery, Queen’s University Belfast, Medical Biology Centre, Belfast, UK
| | | | - Felicity Hasson
- Institute of Nursing and Health Sciences, School of Nursing and Paramedic Sciences Ulster University, Belfast Campus, UK
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Houjaghani H, Mohammadi N, Vahedi Z, Vafaei Shahi M, Behmadi R. The Effect of Birth Hour on Neonatal Morbidity and Mortality in Very-Low Birth Weight Infants in a Teaching Hospital. Turk Arch Pediatr 2023; 58:527-530. [PMID: 37584469 PMCID: PMC10543069 DOI: 10.5152/turkarchpediatr.2023.23071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/16/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE With the increase in the preterm birth rate, the factors influencing mortality and morbidity in very-low-birth weight neonates have gained importance in recent years. The results of available studies on the influence of birth hour on the mortality and morbidity rates of preterm infants are contradictory. Moreover, no study on this topic has been conducted in our region. MATERIALS AND METHODS This retrospective cohort study was conducted on 127 very-low-birth weight newborns based on birth hour. The newborns were divided into 2 groups, the first born during working hours (7:00 am to 11:59 pm) and the second born during after-hours care (12-6:59 am). Mortality and major diseases were compared using Statistical Package for the Social Sciences by Fisher's exact tests, Pearson's chi-squared test, and independent t-tests. The statistical significance level for all analyses was set at P < .05 and the CI at 95%. RESULTS Based on the results of this study in terms of neonatal mortality and major morbidities such as intraventricular hemorrhage and the need for prolonged mechanical ventilation, no significant difference was found between the 2 groups, but the difference in appearance, pulse, grimace, activity, respiration (APGAR) score at the fifth minute was statistically significant and was lower at the working hours. CONCLUSION The results of the study may be due to appropriate allocation of resources, assignment of tasks, and professionalism of care in our study area. Further study is needed to determine the differences in clinical care processes that cause these results.
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Affiliation(s)
- Hirad Houjaghani
- Iran University of Medical Sciences Faculty of Medicine, Tehran, Iran
| | - Nasim Mohammadi
- Iran University of Medical Sciences Faculty of Medicine, Tehran, Iran
| | - Zahra Vahedi
- Iran University of Medical Sciences Faculty of Medicine, Tehran, Iran
| | - Mohammad Vafaei Shahi
- Growth and Development Research Center, Institute of Endocrionology and Metabolism, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Reza Behmadi
- Firoozabadi Clinical Research Development Unit (FACRDU), Iran University of Medical Sciences, Tehran, Iran
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10
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Kjær N, Plejdrup Hansen M, Schou Pedersen H, Bondo Christensen M, Huibers L. Development over time in point-of-care test use in Danish daytime and out-of-hours general practice: a register-based study. Scand J Prim Health Care 2023; 41:108-115. [PMID: 36939231 DOI: 10.1080/02813432.2023.2187667] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023] Open
Abstract
OBJECTIVE To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT). DESIGN AND SETTINGS A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018. SUBJECTS All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period. MAIN OUTCOME MEASURES We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use. RESULTS Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40-59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0-19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing. CONCLUSION The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40-59 years and co-morbidity, while the use of RADT was mostly associated with younger age.
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Affiliation(s)
- Niels Kjær
- Research Unit for General Practice, Aarhus, Denmark
| | | | | | - Morten Bondo Christensen
- Research Unit for General Practice, Aarhus, Denmark
- Institute for Public Health, Aarhus University, Aarhus, Denmark
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Mills SE, Brown-Kerr A, Buchanan D, Donnan PT, Smith BH. Free-text analysis of general practice out-of-hours (GPOOH) use by people with advanced cancer: an analysis of coded and uncoded free-text data. Br J Gen Pract 2023; 73:e124-e132. [PMID: 36702608 PMCID: PMC9888572 DOI: 10.3399/bjgp.2022.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/06/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND People with advanced cancer frequently use the GP out-of-hours (GPOOH) service. Considerable amounts of routine GPOOH data are uncoded. Therefore, these data are omitted from existing healthcare datasets. AIM To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer. DESIGN AND SETTING An analysis of a GPOOH healthcare dataset was undertaken. It contained all coded and free- text information for 5749 attendances from a cohort of 2443 people who died from cancer in Tayside, Scotland, from 2013-2015. METHOD Random sampling methods selected 575 consultations for free-text analysis. Each consultation was analysed by two independent reviewers to determine the following: assigned presenting complaints; key and additional palliative care symptoms recorded in free text; evidence of anticipatory care planning; and free-text recording of dispensed medications. Inter-rater reliability concordance was established through Kappa testing. RESULTS More than half of all coded reasons for attendance (n = 293; 51.0%) were 'other' or 'missing'. Free-text analysis demonstrated that nearly half (n = 284; 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n = 325; 56.5%) recorded at least one key or additional palliative care symptom in free text, with the commonest being breathlessness, vomiting, cough, and nausea. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in more than one- quarter of GPOOH consultations. CONCLUSION GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded. Therefore, it is unrecognised and under-reported in existing large healthcare data analyses.
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Affiliation(s)
- Sarah Ee Mills
- School of Medicine, University of St Andrews, St Andrews
| | | | | | - Peter T Donnan
- Population Health and Genomics Division, University of Dundee Medical School, Ninewells Hospital and Medical School, Dundee
| | - Blair H Smith
- Population Health and Genomics Division, University of Dundee Medical School, Ninewells Hospital and Medical School, Dundee
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Wackers EME, Stadhouders NW, Maessen MFH, Tanke MAC, Gaakeer MI, van Dulmen SA, Jeurissen PPT. Association between acute care collaborations and health care utilization as compared to stand-alone facilities in the Netherlands: a quasi-experimental study. Eur J Emerg Med 2023; 30:15-20. [PMID: 35989654 DOI: 10.1097/MEJ.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.
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Loots FJ, Dekker I, Wang RC, van Zanten AR, Hopstaken RM, Verheij TJ, Giesen P, Smits M. The accuracy and feasibility of respiratory rate measurements in acutely ill adult patients by GPs: a mixed-methods study. BJGP Open 2022; 6:BJGPO. [PMID: 35944945 DOI: 10.3399/BJGPO.2022.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Tachypnoea in acutely ill patients can be an early sign of a life-threatening condition such as sepsis. Routine measurement of the respiratory rate by GPs might improve the recognition of sepsis. AIM To assess the accuracy and feasibility of respiratory rate measurements by GPs. DESIGN & SETTING Observational cross-sectional mixed-methods study in the setting of out-of-hours (OOH) home visits at three GP cooperatives in The Netherlands. METHOD GPs were observed during the assessment of acutely ill patients, and semi-structured interviews were performed. The GP-assessed respiratory rate was compared with a reference measurement. In the event that the respiratory rate was not counted, GPs were asked to estimate the rate (dichotomised as ≥22 breaths per minute or <22 breaths per minute). RESULTS Observations of 130 acutely ill patients were included, and 14 GPs were interviewed. In 33 patients (25%), the GP counted the respiratory rate. A mean difference of 0.27 breaths per minute (95% confidence interval [CI] = -5.7 to 6.3) with the reference measurement was found. At a cut-off point of ≥22 breaths per minute, a sensitivity of 86% (95% CI = 57% to 98%) was found when the GP counted the rate, and a sensitivity of 43% (95% CI = 22% to 66%) when GPs estimated respiratory rates. GPs reported both medical and practical reasons for not routinely measuring the respiratory rate. CONCLUSION GPs are aware of the importance of assessing the respiratory rate of acutely ill adult patients, and counted measurements are accurate. However, in most patients the respiratory rate was not counted, and the rate was often underestimated when estimated.
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Goodrich J, Tutt L, Firth AM, Evans CJ, Murtagh FE, Harding R. The most important components of out-of-hours community care for patients at the end of life: A Delphi study of healthcare professionals' and patient and family carers' perspectives. Palliat Med 2022; 36:1296-1304. [PMID: 35766525 PMCID: PMC9446430 DOI: 10.1177/02692163221106284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Community services for palliative patients outside normal working hours are variable and the best evidence-based models of care have not been determined. AIM To establish expert consensus on the most important components of out-of-hours community palliative care services. DESIGN Delphi study. The first round listed 68 components generated from systematic literature reviewing, focus groups with healthcare professionals and input from the project's patient and public involvement advisory group. The components deemed 'essential' by over 70% of participants in the first round were refined and carried forward to a second round, asking participants to rank each on a five-point Likert scale (5 highest to 1 lowest). The consensus threshold was median of 4 to 5 and interquartile range of ⩽1. PARTICIPANTS Community specialist palliative care health professionals, generalist community health professionals and patients and family carers with experience of receiving care out-of-hours at home. RESULTS Fifty-four participants completed round 1, and 44 round 2. Forty-five components met the threshold as most important for providing out-of-hours care, with highest consensus for: prescription, delivery and administration of medicines; district and community nurse visits; and shared electronic patient records and advance care plans. CONCLUSIONS The Delphi method identified the most important components to provide community palliative care for patients out-of-hours, which are often provided by non-specialist palliative care professionals. The importance placed on the integration and co-ordination with specialist palliative care through shared electronic records and advance care plans demonstrates the reassurance for patients and families of being known to out-of-hours services.
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Affiliation(s)
- Joanna Goodrich
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Lydia Tutt
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Alice M Firth
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Catherine J Evans
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
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Vollam S, Gustafson O, Morgan L, Pattison N, Thomas H, Watkinson P. Patient Harm and Institutional Avoidability of Out-of-Hours Discharge From Intensive Care: An Analysis Using Mixed Methods. Crit Care Med 2022; 50:1083-1092. [PMID: 35245235 PMCID: PMC9197137 DOI: 10.1097/ccm.0000000000005514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night. DESIGN This study was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. We defined out-of-hours discharge as 16:00 to 07:59 hours. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged "probably avoidable" in previous retrospective structured judgment reviews, and 20 where patients survived. We conducted semistructured interviews with 55 patients, family members, and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the human factors-based functional analysis resonance method. SETTING Three U.K. National Health Service hospitals, chosen to represent different hospital settings. SUBJECTS Patients discharged from ICU, their families, and staff involved in their care. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable, and did not have deterioration recognized or escalated appropriately. We identified five interdependent function keys to facilitating timely ICU discharge: multidisciplinary team decision for discharge, patient prepared for discharge, bed meeting, bed manager allocation of beds, and ward bed made available. CONCLUSIONS We identified significant limitations in out-of-hours care provision following overnight discharge from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night.
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Affiliation(s)
- Sarah Vollam
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Owen Gustafson
- Oxford Allied Health Professions Research and Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Lauren Morgan
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Natalie Pattison
- School of Health and Social Work, University of Hertfordshire, Hatfield, United Kingdom
- East and North Herts NHS Trust, Stevenage, United Kingdom
| | - Hilary Thomas
- Centre for Research in Public Health and Community Care, School of Health and Social Work, University of Hertfordshire, Hatfield, United Kingdom
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Brasseur E, Gilbert A, Donneau AF, Monseur J, Ghuysen A, D’Orio V. Reliability and validity of an original nurse telephone triage tool for out-of-hours primary care calls: the SALOMON algorithm. Acta Clin Belg 2022; 77:640-646. [PMID: 34081571 DOI: 10.1080/17843286.2021.1936353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Due to the persistent primary care physicians shortage and the substantial increase in their workload, the organization of primary care calls during out-of-hours periods has become an everyday challenge. The SALOMON algorithm is an original nurse telephone triage tool allowing to dispatch patients to the best level of care according to their conditions. This study evaluated its reliability and criterion validity in rea-life settings. METHODS In this 5-year study, out-of-hours primary care calls were dispatched into four categories: Emergency Medical Services Intervention (EMSI), Emergency Department referred Consultation (EDRC), Primary Care Physician Home visit (PCPH), and Primary Care Physician Delayed visit (PCPD). We included data of patients' triage category, resources, and destination. Patients included into the primary care cohort were classified undertriaged if they had to be redirected to an emergency department (ED). Patients from the ED cohort were considered overtriaged if they did not require at least three diagnostic resources, one emergency-specific treatment or any hospitalization. In the ED cohort, only patients from the University Hospitals were considered. RESULTS 10,207 calls were triaged using the SALOMON tool: 19.2% were classified as EMSI, 15.8% as EDRC, 62.8% as PCPH, and 2.2% as PCPD. The triage was appropriate for 85.5% of the calls with a 14.5% overtriage rate. In the PCPD/PCPH cohort, 96.9% of the calls were accurately triaged and 3.1% were undertriaged. SALOMON sensitivity and specificity reached 76.6% and 98.3%, respectively. CONCLUSION SALOMON algorithm is a valid triage tool that has the potential to improve the organization of out-of-hours primary care work.
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Affiliation(s)
- Edmond Brasseur
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
| | - Allison Gilbert
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
| | - Anne-Françoise Donneau
- Biostatistics Unit, University of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Justine Monseur
- Biostatistics Unit, University of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Alexandre Ghuysen
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
- Public Health Department, University of Liège, Liège, Belgium
| | - Vincent D’Orio
- Emergency Department, University Hospital Center of Liège, Liège, Belgium
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17
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Loots FJ, Smits M, Hopstaken RM, Jenniskens K, Schroeten FH, van den Bruel A, van de Pol AC, Oosterheert JJ, Bouma H, Little P, Moore M, van Delft S, Rijpsma D, Holkenborg J, van Bussel BC, Laven R, Bergmans DC, Hoogerwerf JJ, Latten GH, de Bont EG, Giesen P, Harder AD, Kusters R, van Zanten AR, Verheij TJ. New clinical prediction model for early recognition of sepsis in adult primary care patients: a prospective diagnostic cohort study of development and external validation. Br J Gen Pract 2022; 72:e437-e445. [PMID: 35440467 PMCID: PMC9037184 DOI: 10.3399/bjgp.2021.0520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs. AIM To develop and validate a sepsis prediction model for adult patients in primary care. DESIGN AND SETTING This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020. METHOD Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations. RESULTS A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation. CONCLUSION Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.
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Affiliation(s)
- Feike J Loots
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marleen Smits
- Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Kevin Jenniskens
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Fleur H Schroeten
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ann van den Bruel
- Department of Public Health and Primary Care, Katholieke Universiteit, Leuven, Belgium
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar Bouma
- Department of Clinical Pharmacy and Pharmacology and Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Paul Little
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Moore
- Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | | | - Bas Ct van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre; Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | | | - Dennis Cjj Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre; School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Jacobien J Hoogerwerf
- Department of Internal Medicine and Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen the Netherlands
| | - Gideon Hp Latten
- Emergency Department, Zuyderland Medical Centre, Heerlen; Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Eefje Gpm de Bont
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Paul Giesen
- Scientific Center for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Ron Kusters
- Clinical Chemistry and Haematology, Jeroen Bosch Hospital, Den Bosch; Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Arthur Rh van Zanten
- Gelderse Vallei Hospital, Department of Intensive Care, Ede; Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherlands
| | - Theo Jm Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Morgan T, Tapley A, Davey A, Holliday E, Fielding A, van Driel M, Ball J, Spike N, FitzGerald K, Morgan S, Magin P. Influence of rurality on general practitioner registrars' participation in their practice's after-hours roster: A cross-sectional study. Aust J Rural Health 2022; 30:343-351. [PMID: 35196416 PMCID: PMC9305465 DOI: 10.1111/ajr.12850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate whether practice rurality and rural training pathway are associated with general practitioner registrars' participation in their practice's after‐hours care roster. Design A cross‐sectional analysis of data (2017‐2019) from the Registrar Clinical Encounters in Training study, an ongoing inception cohort study of Australian general practitioner registrars. The principal analyses used logistic regression. Setting Three national general practitioner regional training organisations across 3 Australian states. Participants General practitioner registrars in training within regional training organisations. Main outcome measure Involvement in practice after‐hours care was indicated by a dichotomous response on a 6‐monthly Registrar Clinical Encounters in Training study questionnaire item. Results 1576 registrars provided 3158 observations (response rate 90.3%). Of these, 1574 (48.6% [95% confidence interval: 46.8‐50.3]) involved registrars contributing to their practice's after‐hours roster. In major cities, 40% of registrar terms involved contribution to their practice's after‐hours roster; in regional and remote practices, 62% contributed to the after‐hours roster. On multivariable analysis, both level of rurality of practice (odds ratio(OR) 1.75, P = .007; and OR 1.74, P = .026 for inner regional and outer regional/remote locations, respectively, versus major city) and rural training pathway of registrar (OR 1.65, P = .008) were significantly associated with more after‐hours roster contribution. Other associations were registrars' later training stage, larger practices and practices not routinely bulk billing. Significant regional variability in after‐hours care was identified (after adjusting for rurality). Conclusion These findings suggest that registrars working rurally and those training on the rural pathway are more often participating in practice after‐hours rosters. This has workforce implications, and implications for the educational richness of registrars' training environment.
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Affiliation(s)
- Tobias Morgan
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Amanda Tapley
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy, Regional Training Organisation, Mayfield West, New South Wales, Australia
| | - Andrew Davey
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy, Regional Training Organisation, Mayfield West, New South Wales, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Alison Fielding
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy, Regional Training Organisation, Mayfield West, New South Wales, Australia
| | - Mieke van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Jean Ball
- Clinical Research Design and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Neil Spike
- Department of General Practice and Primary Health Care, University of Melbourne, Carlton, Victoria, Australia.,Eastern Victoria General Practice Training, Regional Training Organisation, Hawthorn, Victoria, Australia
| | - Kristen FitzGerald
- Tasmanian School of Medicine, University of Tasmania, Hobart, Tasmania, Australia.,General Practice Training Tasmania, Regional Training Organisation, Hobart, Tasmania, Australia
| | - Simon Morgan
- NSW & ACT Research and Evaluation Unit, GP Synergy, Regional Training Organisation, Mayfield West, New South Wales, Australia.,Elermore Vale General Practice, Elermore Vale, New South Wales, Australia
| | - Parker Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy, Regional Training Organisation, Mayfield West, New South Wales, Australia
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20
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Kofina V, Lindholm D, Harunani A, Dentino AR, Singh M, Tatakis DN. Post-surgical emergency after-hours calls: Prevalence, concerns, and management. J Dent Educ 2022; 86:814-822. [PMID: 35118665 DOI: 10.1002/jdd.12888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the prevalence, nature, and management of post-surgical emergency after-hours calls in a dental school setting with predoctoral students, graduate students/residents, and faculty providers. METHODS A patient chart review (March 2018-February 2020) for post-surgical calls through the emergency after-hours pager system was conducted at the Marquette University School of Dentistry. The total number of surgical procedures, procedure type, the timing of call, operator experience, concern, and recommendation given during the call were documented. RESULTS During the review period, 83 calls (from 75 patients) were recorded after 8,487 surgical procedures (1% of procedures). Patients were called 5.4 ± 0.8 days postoperatively. Procedure type affected call prevalence (p = 0.04), with most calls made after extractions (69.9% of all calls; 1% of extractions; 58/5,725), implant placement (6%; 0.9% of implant placements; 5/530) and periodontal plastic surgery (6%; 3.1% of all plastic surgeries; 5/161). The most common concern was pain (72.3%), then swelling (36.1%), bleeding (12%), and infection (9.6%). Operator experience did not affect call prevalence. Recommendations given were next business day follow-up (79.5%), reinforcement of already given postoperative instructions (51.8%), prescription (15.7%), and hospital emergency department (ED) visit (7.2%). CONCLUSIONS Post-surgical emergency after-hours calls in a dental school setting occur within the first postoperative week and are rare, unrelated to operator experience, typically prompted by pain, and rarely resulting in referral to hospital ED. The use of a pager system is adequate for the management of after-hours emergencies and may reduce self-referrals to the hospital ED.
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Affiliation(s)
- Vrisiis Kofina
- Department of Surgical Sciences, School of Dentistry, Marquette University, Milwaukee, Wisconsin, USA
| | - Drake Lindholm
- Department of Surgical Sciences, School of Dentistry, Marquette University, Milwaukee, Wisconsin, USA
| | - Abdulkareem Harunani
- Department of Surgical Sciences, School of Dentistry, Marquette University, Milwaukee, Wisconsin, USA
| | - Andrew R Dentino
- Department of Surgical Sciences, School of Dentistry, Marquette University, Milwaukee, Wisconsin, USA
| | - Maharaj Singh
- College of Nursing, Marquette University, Milwaukee, Wisconsin, USA
| | - Dimitris N Tatakis
- Division of Periodontology, College of Dentistry, The Ohio State University, Columbus, Ohio, USA
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21
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Lyness E, Parker J, Willcox ML, Dambha-Miller H. Experiences of out-of-hours task-shifting from GPs: a systematic review of qualitative studies. BJGP Open 2021; 5:BJGPO. [PMID: 34158369 DOI: 10.3399/BJGPO.2021.0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background The current GP workforce is insufficient to manage rising demand in patient care within out-of-hours (OOH) primary care services. To meet this challenge, non-medical practitioners (NMPs) are employed to fulfil tasks traditionally carried out by GPs. It is important to learn from experiences of task-shifting in this setting to inform optimal delivery of care. Aim To synthesise qualitative evidence of experiences of task-shifting in the OOH primary care setting. Design & setting Systematic review of qualitative studies and thematic synthesis. Method Electronic searches were conducted across CINAHL (Cumulative Index of Nursing and Allied Health Literature), PsychINFO, Cochrane, MEDLINE, Embase, and OpenGrey for qualitative studies of urgent or OOH primary care services, utilising task-shifting or role delegation. Included articles were quality appraised and key findings collated through thematic synthesis. Results A total of 2497 studies were screened, of which six met the inclusion criteria. These included interviews with 15 advanced nurse practitioners (ANPs), three physician assistants (PAs), two paramedics, and a focus group of 22 GPs, and focus groups with 33 nurses. Key findings highlight the importance of clearly defining and communicating the scope of practice of NMPs, and of building their confidence by appropriate training, support, and mentoring. Conclusion While NMPs may have the potential to make a substantial contribution to OOH primary care services, there has been very little research on experiences of task-shifting. Evidence to date highlights the need for further training specific to OOH services. Mentorship and support to manage the sometimes challenging cases presenting to OOH could enable more effective OOH services and better patient care.
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22
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Jepson M, Sarkies M, Haines T. Variation in inpatient allied health service provision in Australian and New Zealand hospitals. Australas J Ageing 2021; 41:70-80. [PMID: 34346159 DOI: 10.1111/ajag.12988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 06/24/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the variability of allied health services on weekends, relative to weekdays, throughout Australian and New Zealand hospitals. METHODS A prospective, cross-sectional observational study embedded within a cluster randomised control trial. Allied health managers provided administrative data relating to allied health service events. RESULTS In one month, there were a total of 243 549 allied health service events recorded from 91 sampled hospitals. The mean difference between weekday and weekend allied health service events (daily, per ward) for physiotherapy was 6.52 (95% CI 5.65 to 7.40), acute wards 12.03 (95% CI 10.25 to 13.82) and for metropolitan hospitals 14.47 (95% CI 12.22 to 16.73), revealing more allied health service events of longer duration on weekdays compared to weekends. CONCLUSIONS This research is the first of its kind to describe variation in allied health service provision and potential research to practice gaps across weekday and weekend days in various inpatient settings.
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Affiliation(s)
- Megan Jepson
- Department of Paramedicine, Monash University Peninsula Campus, Melbourne, Vic., Australia.,School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Vic., Australia
| | - Mitchell Sarkies
- School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Vic., Australia.,Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Melbourne, NSW, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University Peninsula Campus, Melbourne, Vic., Australia
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23
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Kaboli PJ, Augustine MR, Rose DE, Chawla N, Bouchard M, Hebert P. Call Center Remote Triage by Nurse Practitioners Was Associated With Fewer Subsequent Face-to-Face Healthcare Visits. J Gen Intern Med 2021; 36:2315-2322. [PMID: 33501532 PMCID: PMC7837076 DOI: 10.1007/s11606-020-06536-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2015, the Veterans Health Administration (VHA) incorporated nurse practitioners (NPs) into remote triage call centers to supplement registered nurse (RN)-handled calls. OBJECTIVE To assess 7-day healthcare use following telephone triage by NPs compared to RNs. We hypothesized that NP clinical decision ability may reduce follow-up healthcare. DESIGN Retrospective observational comparative effectiveness study of clinical and administrative databases. NP routed calls were matched to RN calls based on chief complaint with propensity score matching and multivariate count data models, adjusting for differences in call severity and patient comorbidity. PARTICIPANTS Callers to a VHA regional call center, April 2015 to March 2019. MAIN MEASURES Primary care, specialty care, and emergency department (ED) visits plus hospitalizations within 7 days. KEY RESULTS NP-handled calls (N = 1554) were matched to RN calls (N = 48,024) for the same chief complaint. NP-handled calls, compared to RNs, had lower comorbidities, fewer hospitalizations, and less urgent complaints. Seven-day healthcare use was lower for NP compared to RN calls for specialty care (0.15 vs. 0.20 visits per person [VPP]; p < 0.001), ED (0.11 vs. 0.27 VPP; p < 0.001), and hospitalizations (0.01 vs. 0.04 VPP; p < 0.001), but not primary care (0.43 vs. 0.42 VPP; p = 0.80). In adjusted analyses, estimated avoided in-person visits per 100 calls routed to NPs were 0.7 primary care visits (95% confidence interval [CI] 0.4, 1.0), 2.6 specialty care visits (95% CI 0.0, 5.1), 5.9 ED visits (95% CI 2.7, 9.1), and 1.4 hospital stays (95% CI 0.1, 2.6). Propensity score-matched models comparing NP (N = 1533) to RN (N = 2646) calls had adjusted odds ratios for 7-day healthcare use of 0.75 (primary care), 0.75 (specialty care), and 0.73 (ED) (all p < 0.003). CONCLUSION Incorporating NPs into a call center was associated with lower in-person healthcare use in the subsequent 7 days compared to routine RN-triaged calls.
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Affiliation(s)
- Peter J. Kaboli
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, IA USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Matthew R. Augustine
- Department of Medicine, Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, Bronx, NY USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Danielle E. Rose
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA HSR&D, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Neetu Chawla
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA HSR&D, VA Greater Los Angeles Healthcare System, Los Angeles, CA USA
| | - Maria Bouchard
- VISN 22 Clinical Contact Center, Greater Los Angeles-Sepulveda Advice Call Center, North Hills, CA USA
| | - Paul Hebert
- VA Puget Sound Health Care System, Seattle, WA USA
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24
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Cifarelli CP, McMichael JP, Forman AG, Mihm PA, Cifarelli DT, Lee MR, Marsh W. Surgical Start Time Impact on Hospital Length of Stay for Elective Inpatient Procedures. Cureus 2021; 13:e16259. [PMID: 34277303 PMCID: PMC8269978 DOI: 10.7759/cureus.16259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/28/2022] Open
Abstract
Background Hospital length of stay (LOS) remains an important, albeit nonspecific, metric in the analysis of surgical services. Modifiable factors to reduce LOS are few in number and the ability to practically take action is limited. Surgical scheduling of elective cases remains an important task in optimizing workflow and may impact the post-surgical LOS. Methods Retrospective data from a single tertiary care academic institution were analyzed from elective adult surgical cases performed from 2017 through 2019. Emergent or urgent add-on cases were excluded. Variables included primary procedure, age, diabetes status, American Society of Anesthesiologists (ASA) class, and surgical start time. Analysis of the median LOS following surgery was performed using Mann-Whitney tests and Cox hazards model. Matched-cohort analysis of mean total hospitalization costs was performed using the Student’s t-test. Results 9,258 patients were analyzed across five surgical service lines, of which 777 patients had surgical start time after 3 PM. The median LOS for the after 3 PM group was 1 day longer than the before 3 PM start time cohort (3.0 vs 2.1, p < 0.001). Service line analysis revealed increased LOS for Orthopedics and Neurosurgery (3.0 vs 1.9, p < 0.001; 3.0 vs 2.0, p < 0.05). Multivariate analysis confirmed that start time before 3 PM predicted shorter LOS (HR = 1.214, 1.126-1.309; p < 0.001). Case-matched cost analysis for frequently performed orthopedic and neurosurgical cases with an after 3 PM start time failed to demonstrate a significant difference in total hospital charges. Conclusion Optimization of surgical services scheduling to increase the proportion of elective surgical cases started before 3 PM has the potential to decrease post-surgical LOS for adult patients undergoing Orthopedic or Neurosurgical procedures.
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Affiliation(s)
- Christopher P Cifarelli
- Neurological Surgery, West Virginia University School of Medicine, Morgantown, USA.,Radiation Oncology, West Virginia University School of Medicine, Morgantown, USA
| | | | - Alex G Forman
- Strategic Analytics, West Virginia University School of Medicine, Morgantown, USA
| | - Paul A Mihm
- Surgical Services, West Virginia University School of Medicine, Morgantown, USA
| | - Daniel T Cifarelli
- Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Mark R Lee
- Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Wallis Marsh
- Surgery, West Virginia University School of Medicine, Morgantown, USA
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25
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Barnhoorn PC, Essers GT, Nierkens V, Numans ME, van Mook WN, Kramer AW. Patient complaints in general practice seen through the lens of professionalism: a retrospective observational study. BJGP Open 2021; 5:BJGPO. [PMID: 33589467 DOI: 10.3399/BJGPO.2020.0168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 11/13/2020] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Professionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature of patient complaints in general practice, especially focused on professionalism, is limited. AIM To characterise patient complaints in primary care and to explore in more detail which issues with professionalism exist. DESIGN & SETTING A retrospective observational study in which all unsolicited patient complaints to a representative out-of-hours general practice (OOH GP) service provider in The Netherlands were analysed over a 10-year period (2009-2019). METHOD Complaints were coded for general characteristics and thematically categorised using the CanMEDS Physician Competency Framework (CanMEDS) as sensitising concepts. Complaints categorised as professionalism were subdivided using open coding. RESULTS Out of 746 996 patient consultations (telephone, face-to-face, and home visits) 484 (0.065%) resulted in eligible complaint letters. The majority consisted of two or more complaints, resulting in 833 different complaints. Most complaints concerned GPs (80%); a minority (19%) assistants. Thirty-five per cent concerned perceived professionalism lapses of physicians. A rich diversity in the wording of professionalism lapses was found, where ' not being taken seriously ' was mentioned most often. Forty-five per cent related to medical expertise, such as missed diagnoses or unsuccessful clinical treatment. Nineteen per cent related to management problems, especially waiting times and access to care. Communication issues were only explicitly mentioned in 1% of the complaints. CONCLUSION Most unsolicited patient complaints were related to clinical problems. A third, however, concerned professionalism issues. Not being taken seriously was the most frequent mentioned theme within the professionalism category.
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26
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Loots FJ, Smulders D, Giesen P, Hopstaken RM, Smits M. Vital signs of the systemic inflammatory response syndrome in adult patients with acute infections presenting in out-of-hours primary care: A cross-sectional study. Eur J Gen Pract 2021; 27:83-89. [PMID: 33978531 PMCID: PMC8118397 DOI: 10.1080/13814788.2021.1917544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Signs of the systemic inflammatory response syndrome (SIRS) – fever (or hypothermia), tachycardia and tachypnoea – are used in the hospital setting to identify patients with possible sepsis. Objectives To determine how frequently abnormalities in the vital signs of SIRS are present in adult out-of-hours (OOH) primary care patients with suspected infections and assess the association with acute hospital referral. Methods We conducted a cross-sectional study at the OOH GP cooperative in Nijmegen, the Netherlands, between August and October 2015. GPs were instructed to record the body temperature, heart rate and respiratory rate of all patients with suspected acute infections. Vital signs of SIRS, other relevant signs and symptoms, and referral state were extracted from the electronic registration system of the OOH GP cooperative retrospectively. Logistic regression analysis was used to evaluate the association between clinical signs and hospital referral. Results A total of 558 patients with suspected infections were included. At least two SIRS vital signs were abnormal in 35/409 (8.6%) of the clinic consultations and 60/149 (40.3%) of the home visits. Referral rate increased from 13% when no SIRS vital sign was abnormal to 68% when all three SIRS vital signs were abnormal. Independent associations for referral were found for decreased oxygen saturation, hypotension and rapid illness progression, but not for individual SIRS vital signs. Conclusion Although patients with abnormal vital signs of SIRS were referred more often, decreased oxygen saturation, hypotension and rapid illness progression seem to be most important for GPs to guide further management.
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Affiliation(s)
- Feike J Loots
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Daan Smulders
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul Giesen
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | | | - Marleen Smits
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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27
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Alves PG, Hayward G, Leydon G, Barnes R, Woods C, Webb J, Booker M, Ireton H, Latter S, Little P, Moore M, Nicholls CL, Stevenson F. Antibiotic prescribing in UK out-of-hours primary care services: a realist-informed scoping review of training and guidelines for healthcare professionals. BJGP Open 2021; 5:BJGPO. [PMID: 33757961 DOI: 10.3399/BJGPO.2020.0167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antibiotic overuse has contributed to antimicrobial resistance, which is a global public health problem. In the UK, despite the fall in rates of antibiotic prescription since 2013, prescribing levels remain high in comparison with other European countries. Prescribing in out-of-hours (OOH) care provides unique challenges for prudent prescribing, for which professionals may not be prepared. Aim To explore the guidance available to professionals on prescribing antibiotics for common infections in OOH primary care within the UK, with a focus on training resources, guidelines, and clinical recommendations. Design & setting A realist-informed scoping review of peer-reviewed articles and grey literature. Method The review focused on antibiotic prescribing OOH (for example, clinical guidelines and training videos). General prescribing guidance was searched whenever OOH-focused resources were unavailable. Electronic databases and websites of national agencies and professional societies were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Findings were organised according to realist review components, that is, mechanisms, contexts, and outcomes. Results In total, 46 clinical guidelines and eight training resources were identified. Clinical guidelines targeted adults and children, and included recommendations on prescription strategy, spectrum of the antibiotic prescribed, communication with patients, treatment duration, and decision-making processes. No clinical guidelines or training resources focusing specifically on OOH were found. Conclusion The results highlight a lack of knowledge about whether existing resources address the challenges faced by OOH antibiotic prescribers. Further research is needed to explore the training needs of OOH health professionals, and whether further OOH-focused resources need to be developed given the rates of antibiotic prescribing in this setting.
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28
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Schoenmakers B, Delmeiren L, Pietermans S, Janssens M, Van Der Mullen C, Sabbe M. The implementation of the nationwide out-of-hours phone number 1733 in Belgium: analysis of efficiency and safety. Prim Health Care Res Dev 2021; 22:e7. [PMID: 33715654 DOI: 10.1017/S1463423621000098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Belgium has a problem with inappropriate use of emergency services. The government installed the number 1733 for out-of-hours care. Through a dry run test, we learned that 30% of all calls were allocated to the protocol ‘unclear problem’. In only 11.9% of all cases, there was an unclear problem. Methods: The study aimed to determine whether the adjusted protocol ‘unwell for no clear reason’ led to a safer and more efficient referral and to evaluate the efficiency and safety of the primary care protocols (PCPs). The study ran in cross-sectional design involving patients, General Practitioner Cooperatives and telephone operators. A random sample of calls to 1733 and patient referrals were assessed on efficiency and safety. Results: During 6 months in 2018, 11 622 calls to 1733 were registered. Seven hundred fifty-six of them were allocated to ‘unwell for no clear reason’, and a random sample of 180 calls was audited. To evaluate the PCPs, 202 calls were audited. The efficiency and safety of the protocol ‘unwell for no clear reason’ improved, and safety levels for under- and over-triage were not exceeded. The GP’s judged that 9/10 of all patient encounters were correctly referred. Conclusion: This study demonstrated that the 1733-telephone triage system for out-of-hours care is successful if protocols, flow charts and emergency levels are well defined, monitored and operators are trained.
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Basmaji J, Priestap F, Chehadi W, Ip WWC, Martin C, Kao R. A retrospective observational study of daytime and nighttime transfers from the intensive care unit: through the lens of critical care response teams. Can J Anaesth 2021; 68:336-344. [PMID: 33403539 DOI: 10.1007/s12630-020-01874-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To evaluate the impact of nighttime compared with daytime transfers from the intensive care unit (ICU) on mortality in a hospital with a critical care response team (CCRT). METHODS We performed a retrospective observational study of ICU patients transferred between January 2011 and July 2013 who received CCRT follow-up. The transferred patients were divided into cohorts of daytime and nighttime transfers. A multivariable logistic regression model was used to identify independent predictors of mortality after ICU transfer. RESULTS There were 1,857 patients included in the study. With the exception of Multiple Organ Dysfunction Score on admission, transfers to a step-down unit, and lower urine output, there were no differences in the baseline characteristics, clinical events identified by CCRTs, and the number of CCRT interventions performed between daytime and nighttime transfers. Patients transferred at night were at higher risk of death in the univariate analysis but not in the multivariate analysis. Independent predictors of mortality included older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002 to 1.04), transfer to a medical service (OR, 1.96; 95% CI, 1.11 to 3.43), CCRT identification of hypoxemic respiratory failure (OR, 5.86; 95% CI, 3.11 to 11.04), decreased level of consciousness (OR, 3.14; 95% CI, 1.23 to 8.02), hypotension (OR, 3.69; 95% CI, 1.36 to 10.01), and longer CCRT duration of follow-up (OR, 1.02; 95% CI, 1.004 to 1.03). CONCLUSIONS Nighttime transfer from the ICU was not an independent predictor of mortality. We identified unique predictors of mortality, including clinical events that CCRTs identified in patients immediately after ICU transfer. Future studies are required to validate these predictors of mortality in transferred ICU patients.
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Affiliation(s)
- John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Fran Priestap
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Waleed Chehadi
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Critical Care, Department of Medicine, St. Thomas Elgin General Hospital, St. Thomas, ON, Canada
| | - William Wang-Chun Ip
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Claudio Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Raymond Kao
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Fife A. The Dark Side: Development and Implementation of an Overnight Pediatric Pharmacy Emergency Medicine Rotation. J Pediatr Pharmacol Ther 2021; 26:213-215. [PMID: 33603588 DOI: 10.5863/1551-6776-26.2.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/28/2020] [Indexed: 11/11/2022]
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Jones A, Bronskill SE, Schumacher C, Seow H, Feeny D, Costa AP. Effect of Access to After-Hours Primary Care on the Association Between Home Nursing Visits and Same-Day Emergency Department Use. Ann Fam Med 2020; 18:406-412. [PMID: 32928756 PMCID: PMC7489957 DOI: 10.1370/afm.2571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/29/2020] [Accepted: 02/05/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Previous work has demonstrated that home care patients have an increased risk of visiting the emergency department after a home nursing visit on the same day. We investigated whether this association is modified by greater access to after-hours primary care. METHODS We conducted a population-based case-crossover study of home care patients in Ontario, Canada in 2014-2016. Emergency department visits after 5:00 pm were selected as case periods and matched, within the same patient, to control periods within the previous week. The association between home nursing visits and same-day emergency department visits was estimated with conditional logistic regression. Access to after-hours primary care, measured on the patient and practice level, was tested for effect modification using an interaction term approach. Analysis was performed separately for all emergency department visits and a less urgent subset not admitted to hospital. RESULTS A total of 11,840 patients contributed cases to the analysis. Patients with a history of after-hours primary care use had a smaller increased risk of a same-day after-hours emergency department visit (OR = 1.18; 95% CI, 1.06-1.30) compared with patients with no after-hours care (OR = 1.31; 95% CI, 1.25-1.39). The modifying effect was stronger among emergency department visits not admitted to hospital (OR = 1.11; 95% CI, 0.97-1.28 vs OR = 1.41; 95% CI, 1.31-1.51). CONCLUSION Greater access to after-hours primary care reduced the risk of less-urgent emergency department use associated with home nursing visits. These findings suggest increasing access to after-hours primary care could prevent some less-urgent emergency department visits.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto
| | - Connie Schumacher
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Hsien Seow
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - David Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Lin MH, Chen HN, Chen TJ. Changes in 24-Hour Palliative Care Telephone Advice Service after the Introduction of Discharged End-of-Life Patients' Care Plans. Int J Environ Res Public Health 2020; 17:E5876. [PMID: 32823626 DOI: 10.3390/ijerph17165876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 12/05/2022]
Abstract
Background: To provide a better quality of death for patients at the end of life who choose to die at home and their families, the hospice care team at Taipei Veterans General Hospital has promoted an personalized discharged end-of-life care plan since the initial of 2018. Methods: This study is a retrospective analysis of administrative data. All incoming calls of the 24-hour specialist palliative care emergency telephone advice service records were analyzed. Personal information of any callers or consultants was not registered in the content. Results: A total of 728 telephone consultations was registered during the study period. The content of the consultation of different callers was significantly different (p < 0.001). The decrease in the number of calls from the patients who were discharged from the hospice ward had the largest reduction in proportion, from 80 (19.0%) to 32 (10.5%), There was a significant difference in the identity of the callers between 2017 and 2018 (p = 0.025). The proportion of consultation calls for the management of near-death symptoms significantly reduced from 15.6% to 10.5% (p = 0.027). Conclusions: Though the evidence from this study is not enough to support that the personalized discharged end-of-life care plan might reduce the frequency of dialing 24-hour hotlines by the family members of discharged terminally ill patients. For patients who choose to die at home and their families, the hotlines provide a 24-hour humane support. Thus, we need to conduct relevant research to determine whether the service of this dedicated line meets the needs of patients and their families in the terminal stage.
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Bernet S, Gut L, Baechli C, Koch D, Wagner U, Mueller B, Schuetz P, Kutz A. Association of weekend admission and clinical outcomes in hospitalized patients with sepsis: An observational study. Medicine (Baltimore) 2020; 99:e20842. [PMID: 32590778 PMCID: PMC7329016 DOI: 10.1097/md.0000000000020842] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Sepsis is associated with impaired clinical outcomes. It requires timely diagnosis and urgent therapeutic management. Because staffing during after-hours is limited, we explored whether after-hour admissions are associated with worse clinical outcomes in patients with sepsis.In this retrospective cohort study, we analyzed nationwide acute care admissions for a main diagnosis of sepsis in Switzerland between 2006 and 2016 using prospective administrative data. The primary outcome was in-hospital mortality using multivariable logistic regression models. Secondary outcomes were intensive care unit (ICU) admission, intubation, and 30-day readmission.We included 86,597 hospitalizations for sepsis, 60.1% admitted during routine-hours, 16.8% on weekends and 23.1% during night shift. Compared to routine-hours, we found a higher odds ratio (OR) for in-hospital mortality in patients admitted on weekends (Adjusted OR 1.05, 95% confidence interval [95% CI] 1.01, 1.10, P = .041). Also, the OR for ICU admission (OR 1.14, 95% CI 1.10, 1.19, P < .001) and intubation (OR 1.18, 95% CI 1.12, 1.25 P < .001) was higher for weekends compared to routine-hours. Regarding 30-day readmission, evidence for an association could not be observed. Night shift admission, compared to routine-hours, was associated with a higher OR for ICU admission and intubation (ICU admission: OR 1.28 (1.23, 1.32), P < .001; intubation: OR 1.31, 95% CI 1.25, 1.37, P < .001) but with a lower OR for in-hospital mortality (OR 0.93, 19% CI 0.89, 0.97, P = .001).Among hospitalizations with a main diagnosis of sepsis, weekend admissions were associated with higher OR for in-hospital mortality, ICU admission, and intubation. Whether these findings can be explained by staffing-level differences needs to be addressed.
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Affiliation(s)
- Selina Bernet
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | - Lara Gut
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | - Ciril Baechli
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | - Daniel Koch
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | | | - Beat Mueller
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
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Abstract
Background: Overuse of antibiotics and inappropriate prescribing has resulted in a rapid increase in the rate of antibiotic resistance, with poorer patient outcomes and increased health costs. In the out-of-hours setting, a high proportion of antibiotics are prescribed and practices need to improve to reduce antibiotic resistance. Purpose: To identify antibiotic prescribing practices in European out-of-hours primary care services that are contributing to antibiotic resistance. Design: The review was conducted in alignment with the PRISMA statement (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009). Methods: A literature search was performed using MySearch to identify European literature. The search was focused on antibiotic/antimicrobial prescribing in an out-of-hours environment, and any reports that described factors correlating with the nature of prescribing practices were examined. Results: The literature search located 91 articles, out of which seven met the inclusion criteria. Two articles described clinicians’ experiences in antibiotic prescribing in out-of-hours, two compared in-office and after-hours prescribing, two described prescribing patterns in out-of-hours and one examined prescribing in children. Four main themes were identified: antibiotics prescribed and conditions associated with prescribing; consultation time; the day of consultation; and parental opinion. Conclusion: Overprescribing to self-limiting conditions, prescribing of broad-spectrum antibiotics, time constraints, safeguarding issues and poor communication are all contributing to inappropriate antibiotic prescribing. Further research is needed relating to whether clinicians are adhering to antibiotic guidelines and to explore patients’ experiences and expectations from the out-of-hours practitioners with respect to antibiotic prescribing.
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Affiliation(s)
- Jasmine Hart
- South Western Ambulance Service NHS Foundation Trust
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Finucane AM, Davydaitis D, Horseman Z, Carduff E, Baughan P, Tapsfield J, Spiller JA, Meade R, Lydon B, Thompson IM, Boyd KJ, Murray SA. Electronic care coordination systems for people with advanced progressive illness: a mixed-methods evaluation in Scottish primary care. Br J Gen Pract 2020; 70:e20-8. [PMID: 31848198 DOI: 10.3399/bjgp19X707117] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/09/2019] [Indexed: 11/29/2022] Open
Abstract
Background Electronic care coordination systems, known as the Key Information Summary (KIS) in Scotland, enable the creation of shared electronic records available across healthcare settings. A KIS provides clinicians with essential information to guide decision making for people likely to need emergency or out-of-hours care. Aim To estimate the proportion of people with an advanced progressive illness with a KIS by the time of death, to examine when planning information is documented, and suggest improvements for electronic care coordination systems. Design and setting This was a mixed-methods study involving 18 diverse general practices in Scotland. Method Retrospective review of medical records of patients who died in 2017, and semi-structured interviews with healthcare professionals were conducted. Results Data on 1304 decedents were collected. Of those with an advanced progressive illness (79%, n = 1034), 69% (n = 712) had a KIS. These were started a median of 45 weeks before death. People with cancer were most likely to have a KIS (80%, n = 288), and those with organ failure least likely (47%, n = 125). Overall, 68% (n = 482) of KIS included resuscitation status and 55% (n = 390) preferred place of care. People with a KIS were more likely to die in the community compared to those without one (61% versus 30%). Most KIS were considered useful/highly useful. Up-to-date free-text information within the KIS was valued highly. Conclusion In Scotland, most people with an advanced progressive illness have an electronic care coordination record by the time of death. This is an achievement. To improve further, better informal carer information, regular updating, and a focus on generating a KIS for people with organ failure is warranted.
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Mills S, Buchanan D, Guthrie B, Donnan P, Smith B. Factors affecting use of unscheduled care for people with advanced cancer: a retrospective cohort study in Scotland. Br J Gen Pract 2019; 69:e860-8. [PMID: 31740459 DOI: 10.3399/bjgp19X706637] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background People with advanced cancer frequently attend unscheduled care, but little is known about the factors influencing presentations. Most research focuses on accident and emergency (A&E) and does not consider GP out-of-hours (GPOOH). Aim To describe the frequency and patterns of unscheduled care use by people with cancer in their last year of life and to examine the associations of demographic and clinical factors with unscheduled care attendance. Design and setting Retrospective cohort study of all 2443 people who died from cancer in Tayside, Scotland, during 2012–2015. Clinical population datasets were linked to routinely collected clinical data using the Community Health Index (CHI) number. Method Anonymised CHI-linked data were analysed in SafeHaven, with descriptive analysis, using binary logistic regression for adjusted associations. Results Of the people who died from cancer, 77.9% (n = 1904) attended unscheduled care in the year before death. Among unscheduled care users, most only attended GPOOH (n = 1070, 56.2%), with the rest attending A&E only (n = 204, 10.7%), or both (n = 630, 33.1%). Many attendances occurred in the last week (n =1360, 19.7%), last 4 weeks (n = 2541, 36.7%), and last 12 weeks (n = 4174, 60.3%) of life. Age, sex, deprivation, and cancer type were not significantly associated with unscheduled care attendance. People living in rural areas were less likely to attend unscheduled care: adjusted odds ratio (aOR) 0.64 (95% confidence interval = 0.50 to 0.82). Pain was the commonest coded clinical reason for presenting (GPOOH: n = 482, 10.5%; A&E: n = 336, 28.8%). Of people dying from cancer, n = 514, 21.0%, were frequent users (≥5 attendances/year), and accounted for over half (n = 3986, 57.7%) of unscheduled care attendances. Conclusion Unscheduled care attendance by people with advanced cancer was substantially higher than previously reported, increased dramatically towards the end of life, was largely independent of demographic factors and cancer type, and was commonly for pain and palliative care.
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Hedden L, Lavergne MR, McGrail KM, Law MR, Bourgeault IL, McCracken R, Barer ML. Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia. Ann Fam Med 2019; 17:116-124. [PMID: 30858254 PMCID: PMC6411390 DOI: 10.1370/afm.2366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/23/2018] [Accepted: 12/17/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Providing care in alternative (non-office) locations and outside office hours are important elements of access and comprehensiveness of primary care. We examined the trends in and determinants of the services provided in a cohort of primary care physicians in British Columbia, Canada. METHODS We used physician-level payments for all primary care physicians practicing in British Columbia from 2006-2007 through 2011-2012. We examined the association between physician demographics and practice characteristics and payment for care in alternative locations and after hours across rural, urban, and metropolitan areas using longitudinal mixed-effects models. RESULTS The proportion of physicians who provided care in alternative locations and after hours declined significantly during the period, in rural, urban, and metropolitan practices. Declines ranged from 5% for long-term care facility visits to 22% for after-hours care. Female physicians, and those in the oldest age category, had lower odds of providing care at alternative locations and for urgent after-hours care. Compared with those practicing in metropolitan centers, physicians working in rural areas had significantly higher odds of providing care both in alternative locations and after hours. CONCLUSION Care provided in non-office locations and after office hours declined significantly during the study period. Jurisdictions where providing these services are not mandated, and where similar workforce demographic shifts are occurring, may experience similar accessibility challenges.
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Affiliation(s)
- Lindsay Hedden
- Centre for Clinical Epidemiology and Evaluation, Research Pavilion, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - M Ruth Lavergne
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kimberlyn M McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ivy L Bourgeault
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Rita McCracken
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Morris L Barer
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
OBJECTIVE To identify baseline predictors of symptom duration after empirical treatment for uncomplicated urinary tract infection (UTI) and significant bacteriuria in a cohort of women treated for UTI. DESIGN Prospective single-centre cohort study. SETTING Outpatient clinic in Norway. PATIENTS From September 2010 to November 2011, 441 women aged 16-55 years with symptoms of uncomplicated UTI were included. RESULTS Dipstick findings of leukocyte esterase 1 + (incidence rate ratio (IRR) 1.93, 95% confidence interval (CI) 1.23-3.01, p < 0.01) and microbe resistant to mecillinam treatment (IRR 1.41, 95% CI 1.07-1.89, p = 0.02) predicted longer symptom duration. More pronounced symptoms did not predict longer symptom duration (IRR 1.18, 95% CI 0.94-1.46, p = 0.15) or significant bacteriuria (odds ratio [OR] 1.16, 95% CI 0.72-1.88, p = 0.54). Leukocyte esterase 2 + (OR 2.51, 95% CI 0.92-6.83, p = 0.07) or 3 + (OR 2.40, 95% CI 0.88-6.05, p = 0.09) and nitrite positive urine dipstick test (OR 3.22, 95% CI 1.58-7.01, p = <0.01) were associated with bacteriuria. CONCLUSION More pronounced symptoms did not correlate with significant bacteriuria or symptom duration after empirical treatment for acute cystitis. One might reconsider the current practice of treating uncomplicated UTI based on symptoms alone. Key Points Treatment strategies for milder infectious diseases must consider ways of reducing antibiotic consumption to decelerate the increase in antibiotic resistance. Our findings suggest that more emphasis should be put on urine dipstick results and bacteriological findings in the clinical setting. One might reconsider the current practice of treating uncomplicated UTIs based on symptoms alone.
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Affiliation(s)
- Marianne Bollestad
- The Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
- Oslo Accident and Emergency Outpatient Clinic, Department of Emergency General Practice, City of Oslo Health Agency, Oslo, Norway;
- Division of Medicine, Stavanger University Hospital, Stavanger, Norway;
- CONTACT Marianne Bollestad Stavanger University Hospital, Pb. 8100 Forus, 4068Stavanger, Norway
| | - Ingvild Vik
- The Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
- Oslo Accident and Emergency Outpatient Clinic, Department of Emergency General Practice, City of Oslo Health Agency, Oslo, Norway;
| | - Nils Grude
- The Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
- Department of Medical Microbiology, Vestfold hospital trust, Toensberg, Norway
| | - Morten Lindbæk
- The Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway;
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McKenzie GAG. Evidence-based out-of-hours hospital medicine. Postgrad Med J 2018; 94:588-595. [PMID: 30373909 DOI: 10.1136/postgradmedj-2017-135049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/14/2017] [Accepted: 09/28/2018] [Indexed: 11/04/2022]
Abstract
Out-of-hours (OOH) hospital ward cover is generally provided by junior doctors and is typified by heavy workloads, reduced staff numbers and various non-urgent nurse-initiated requests. The present inefficiencies and management problems with the OOH service are reflected by the high number of quality improvement projects recently published. In this narrative review, five common situations peculiar to the OOH general ward setting are discussed with reference to potential areas of inefficiency and unnecessary management steps: (1) prescription of hypnotics and sedatives; (2) overnight fluid therapy; (3) fever; (4) overnight hypotension and (5) chasing outstanding routine diagnostic tests. It is evident that research and consensus guidelines for many clinical situations in the OOH setting are a neglected arena. Many recommendations made herein are based on expert opinion or first principles. In contrast, the management of significant abnormalities in outstanding blood results is based on well-established guidelines using high-quality systematic reviews.
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Huibers L, Keizer E, Carlsen AH, Moth G, Smits M, Senn O, Christensen MB. Help-seeking behaviour outside office hours in Denmark, the Netherlands and Switzerland: a questionnaire study exploring responses to hypothetical cases. BMJ Open 2018; 8:e019295. [PMID: 30341108 PMCID: PMC6196844 DOI: 10.1136/bmjopen-2017-019295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 05/11/2018] [Accepted: 06/14/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We aim to study the preferred behaviour among individuals from different age groups in three countries when acute health problems occur outside office hours and thereby to explore variations in help-seeking behaviour. DESIGN A questionnaire study exploring responses to six hypothetical cases describing situations with a potential need for seeking medical care and questions on background characteristics. SETTING General population in Denmark, the Netherlands and Switzerland. POPULATION Danish, Dutch and Swiss individuals from three age groups (0-4, 30-39, 50-59 years). MAIN OUTCOME MEASURES Distribution of intended help-seeking preferences per case per age group, compared between countries. Differences in percentage of help-seeking outside office hours per age group and country, crude and adjusted for background characteristics. RESULTS Danish and Dutch parents of children aged 0-4 years differed in intended help-seeking behaviour for five out of six cases (abdominal pain, red eyes, rash, relapse fever, chickenpox); Danish parents significantly more often chose to contact out-of-hours (OOH) care than Dutch parents. For adults aged 30-39 years, no significant difference between the three countries was found for contacting OOH care. Swiss adults aged 50-59 years had the highest percentage of OOH contacts (38.3%), followed by the Danish (33.4%) and the Dutch (32.5%). CONCLUSION Some differences in help-seeking behaviour outside office hours exist between Danish, Dutch and Swiss individuals, particularly for parents of young children. The question remains whether these differences result from individual preferences, cultural disparities and/or health services variations. Future research should focus on identifying explanations for these differences to reduce undesirable use of OOH care.
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Affiliation(s)
| | - Ellen Keizer
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | | | - Grete Moth
- Research Unit for General Practice, Aarhus, Denmark
| | - Marleen Smits
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
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Kiran T, Moineddin R, Kopp A, Frymire E, Glazier RH. Emergency Department Use and Enrollment in a Medical Home Providing After-Hours Care. Ann Fam Med 2018; 16:419-427. [PMID: 30201638 PMCID: PMC6130993 DOI: 10.1370/afm.2291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 05/07/2018] [Accepted: 06/07/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Compared with other high-income countries, Canada and the United States have among the highest rates of emergency department use and the lowest rates of primary care physicians reporting arrangements for after-hours care. We assessed whether enrollment in a medical home mandated to provide after-hours care in Ontario, Canada, was associated with reduced emergency department use. METHODS We conducted a retrospective cohort study using linked administrative data. We included all adult Ontarians enrolled in a medical home between April 1, 2005, and March 31, 2012, who had a minimum of 3 years of outcome data before and after enrollment (N = 2,945,087). We performed a linear segmented analysis with patient-level data to understand the association between initial enrollment in a medical home and emergency department visits, the proportion of all primary care visits occurring on the weekend, and the primary care visit rate. Age, income quintile, comorbidity, and morbidity were included in the modeling as time-varying covariates and sex as a stable variable. RESULTS The emergency department visit rate increased by 0.8% (95% CI, 0.7% to 0.9%) per year before medical home enrollment and by 1.5% (95% CI, 1.4% to 1.5%) per year after the transition. Enrollment in a medical home was associated with an increase in the proportion of visits that occurred on weekends, but a decrease in the overall primary care visit rate. CONCLUSIONS Enrollment of adult Ontarians in a primary care medical home offering after-hours care was not associated with a reduction in emergency department use. It will therefore be important to prospectively evaluate policy reforms aimed at improving access to primary care outside of conventional hours.
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Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine and the Centre for Urban Health Solutions in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada .,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health Quality Ontario, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Alexander Kopp
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eliot Frymire
- Institute for Clinical Evaluative Sciences, Kingston, Ontario, Canada.,Centre for Health Services and Policy Research, Queens University, Kingston, Canada
| | - Richard H Glazier
- Department of Family and Community Medicine and the Centre for Urban Health Solutions in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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42
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Lee CH, Yoon H, Choi YJ, Jang ES, Kim J, Shin CM, Park YS, Hwang JH, Kim JW, Jeong SH, Kim N, Lee DH, Kim JS. Predictive factors of therapeutic intervention in on-call endoscopy for suspected gastrointestinal bleeding. Scand J Gastroenterol 2018; 53:958-963. [PMID: 30134741 DOI: 10.1080/00365521.2018.1493533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Performing an endoscopy out of hours confer significant burdens on limited health-care resources. However, not all on-call endoscopies lead to therapeutic interventions. The purpose of the present study was to analyze predictive factors for performing therapeutic intervention in patients with suspected gastrointestinal bleeding. METHODS We reviewed and analyzed electronic medical records regarding on-call endoscopy that were prospectively collected for quality control. The subjects were patients with suspected gastrointestinal bleeding who underwent on-call endoscopies at night, on weekends and on holidays between April 2013 and January 2017 in Seoul National University Bundang Hospital. To determine predictive factors for performing therapeutic intervention, the following variables were analyzed: symptoms, patient status, coexisting disease, laboratory findings and medications. To clarify the association between the likelihood of therapeutic intervention in on-call endoscopy and AIMS65 score, the included variables were divided by cutoffs. RESULTS A total of 270 patients (male: 72.6%, mean age: 62.6 years) with suspected gastrointestinal bleeding had on-call endoscopies and 153 (56.7%) patients had therapeutic intervention. Gastroscopy, colonoscopy and both endoscopic techniques were performed in 215, 42 and 13 patients, respectively. In the multivariate analysis, hematemesis (p < .001, odds ratio [OR], 2.484) and prolonged prothrombin time-international normalized ratio (PT-INR) (p = .033; OR, 1.958) were correlated with performing therapeutic intervention in on-call endoscopy. AIMS65 score with a cutoff of 2 was associated with the likelihood of intervention (p = .043). CONCLUSIONS Hematemesis and prolonged PT-INR were predictive factors of therapeutic intervention when on-call endoscopy was performed in patients with suspected gastrointestinal bleeding.
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Affiliation(s)
- Chan Hyung Lee
- a Department of Internal Medicine and Liver Research Institute , Seoul National University College of Medicine , Seoul , South Korea.,b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Hyuk Yoon
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Yoon Jin Choi
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Eun Sun Jang
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Jaihwan Kim
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Cheol Min Shin
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Young Soo Park
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Jin-Hyeok Hwang
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Jin-Wook Kim
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Sook-Hayng Jeong
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Nayoung Kim
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Dong Ho Lee
- b Department of Internal Medicine , Seoul National University Bundang Hospital , Seongnam , Gyeonggi-do , South Korea
| | - Joo Sung Kim
- a Department of Internal Medicine and Liver Research Institute , Seoul National University College of Medicine , Seoul , South Korea
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Thabet FC, alHaffaf FA, Bougmiza IM, Bafaqih HA, Chehab MS, alMohaimeed SA. Off-Hours Admissions and Mortality in PICU Without 24-Hour Onsite Intensivist Coverage. J Intensive Care Med 2018; 35:694-699. [PMID: 29788796 DOI: 10.1177/0885066618778824] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate whether the off-hours admission has any effect on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (PICU) without 24-hour in-house intensivist coverage. DESIGN Prospective cohort study. SETTING A 34-bed tertiary PICU. PATIENTS All consecutive nonelective patients aged 0 to 14 years admitted from January 2012 to June 2015. MEASUREMENTS AND MAIN RESULTS A total of 1254 patients were nonelectively admitted to the PICU. They were categorized according to time of PICU admission as either office hours (07:30 to 16:30 from Sunday to Thursday and whenever an intensivist is present in the ICU) or off-hours (16:30 to 07:30, Friday and Saturday and public holidays). Standardized mortality rates (SMRs) of patients admitted during off-hours were compared to SMRs of patients admitted during office hours using Pediatric Risk of Mortality (PRISM2) score. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the PRISM2. The mortality observed in the office-hours group was 9.4% and in the off-hours group was 8.1%. The PRISM2-based SMR was 0.83 (95% confidence interval [CI]: 0.43-1.47) for the office-hours group and 0.68 (95% CI: 0.34-1.36) for the off-hours group. No significant differences in length of ICU stay or duration of mechanical ventilation were observed between patients admitted during off-hours and those admitted during office hours. In the logistic regression model, off-hours admission was not significantly associated with a higher mortality (odds ratio: 0.85, 95% CI: 0.57-1.27; P = .44). CONCLUSIONS The absence of an in-house intensivist during off-hours is not associated with an increase in mortality, length of ICU stay, or duration of mechanical ventilation for patients admitted to our pediatric ICU.
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Affiliation(s)
- Farah Chedly Thabet
- Pediatric department, Pediatric Intensive Care Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Faisal Ahmed alHaffaf
- Pediatric department, Pediatric Intensive Care Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Hend Ali Bafaqih
- Pediatric department, Pediatric Intensive Care Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - May Said Chehab
- Pediatric department, Pediatric Intensive Care Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Abstract
BACKGROUND Continuity of care is important for palliative patients in their end of life. In the Netherlands, after-hours primary care for palliative patients is either provided by large-scale general practitioner (GP) cooperatives or GPs choose to give palliative care by themselves while they are not on duty. AIM To examine the availability of, perceived problems by, and attitude of Dutch GPs regarding providing palliative care for their own patients outside office hours. DESIGN AND SETTING Cross-sectional observational study among 1772 GPs from 10 Dutch regions. METHOD Online questionnaire among GPs affiliated with 10 GP cooperatives. RESULTS Five hundred twenty-four (29.6%) eligible questionnaires were returned. Of the GPs, 60.8% were personally available outside office hours for their own palliative patients on their own private cell phone and performed home visits if needed. In 33.0%, GPs were willing to make home visits in private time instigated by the GP cooperative and 26.8% were only accessible for telephone consultation by the GP cooperative. In 12.2%, the GP delegated after-hours palliative care completely to the GP cooperative. The GPs predominantly reported "time pressure" problems (17.3%) as a barrier and 61.7% stated that after-hours palliative care is the responsibility of the own GP. CONCLUSION The large majority of Dutch GPs is personally available for telephone consultation and/or willing to provide palliative care for their own patients outside office hours. For the future, it is important to maintain the willingness of GPs to remain personally available for their palliative patients.
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Affiliation(s)
- Fredrik M Plat
- 1 Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Yvonne A S Peters
- 2 IMPULS, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul Giesen
- 1 Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Gamst-Jensen H, Huibers L, Pedersen K, Christensen EF, Ersbøll AK, Lippert FK, Egerod I. Self-rated worry in acute care telephone triage: a mixed-methods study. Br J Gen Pract 2018; 68:e197-203. [PMID: 29440015 DOI: 10.3399/bjgp18X695021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/02/2017] [Indexed: 11/29/2022] Open
Abstract
Background Telephone triage is used to assess acute illness or injury. Clinical decision making is often assisted by triage tools that lack callers’ perspectives. This study analysed callers’ perception of urgency, defined as degree of worry in acute care telephone calls. Aim To explore the caller’s ability to quantify their degree of worry, the association between degree of worry and variables related to the caller, the effect of degree of worry on triage outcome, and the thematic content of the caller’s worry. Design and setting A mixed-methods study with simultaneous convergent design combining descriptive statistics and thematic analysis of 180 calls to a Danish out-of-hours service. Method The following quantitative data were measured: age of caller, sex, reason for encounter, symptom duration, triage outcome, and degree of worry (rated from 1 = minimally worried to 5 = extremely worried). Qualitative data consisted of audio-recorded telephone calls. Results Most callers (170 out of 180) were able to scale their worry when contacting the out-of-hours service (median = 3, interquartile range = 2–4, mean = 2.76). Degree of worry was associated with female sex (odds ratio [OR] 1.98, 95% CI = 1.13 to 3.45) and symptom duration (>24 hours: OR 2.01, 95% CI = 1.13 to 3.45) (reference <5 hours), but not with age or reason for encounter. A high degree of worry significantly increased the chance of being triaged to a face-to-face consultation. The thematic content of worry varied from emotions of feeling bothered to feeling distressed. Callers provided more contextual information when asked about their degree of worry. Conclusion Callers were able to rate their degree of worry. The degree of worry scale is feasible for larger-scale studies if incorporating a patient-centred approach in out-of-hours telephone triage.
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Broadway B, Kalb G, Li J, Scott A. Do Financial Incentives Influence GPs' Decisions to Do After-hours Work? A Discrete Choice Labour Supply Model. Health Econ 2017; 26:e52-e66. [PMID: 28217847 DOI: 10.1002/hec.3476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 10/14/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
This paper analyses doctors' supply of after-hours care (AHC), and how it is affected by personal and family circumstances as well as the earnings structure. We use detailed survey data from a large sample of Australian General Practitioners (GPs) to estimate a structural, discrete choice model of labour supply and AHC. This allows us to jointly model GPs' decisions on the number of daytime-weekday working hours and the probability of providing AHC. We simulate GPs' labour supply responses to an increase in hourly earnings, both in a daytime-weekday setting and for AHC. GPs increase their daytime-weekday working hours if their hourly earnings in this setting increase, but only to a very small extent. GPs are somewhat more likely to provide AHC if their hourly earnings in that setting increase, but again, the effect is very small and only evident in some subgroups. Moreover, higher earnings in weekday-daytime practice reduce the probability of providing AHC, particularly for men. Increasing GPs' earnings appears to be at best relatively ineffective in encouraging increased provision of AHC and may even prove harmful if incentives are not well targeted. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Barbara Broadway
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
- ARC Centre of Excellence for Children and Families over the Life Course, Indooroopilly, QLD, Australia
| | - Guyonne Kalb
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
- ARC Centre of Excellence for Children and Families over the Life Course, Indooroopilly, QLD, Australia
- Institute for the Study of Labor (IZA), Bonn, Germany
| | - Jinhu Li
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
- ARC Centre of Excellence for Children and Families over the Life Course, Indooroopilly, QLD, Australia
| | - Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
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Devroey M, Buyse C, Norrenberg M, Ros AM, Vincent JL. Cardiorespiratory Physiotherapy around the Clock: Experience at a University Hospital. Physiother Can 2016; 68:254-258. [PMID: 27909374 DOI: 10.3138/ptc.2015-40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: To document and describe the use of a hospital-wide, 24-hour cardiorespiratory physiotherapy service run by an intensive care unit (ICU) team of physiotherapists. Methods: We prospectively collected data on all non-ICU hospital patients who used the 24-hours-per-day cardiorespiratory physiotherapy service over a 1-year period between July 2013 and June 2014. The ICU physiotherapists documented the reason, origin of referral, time of call, and type and frequency of treatment of each patient. Results: Over the 1-year period, the ICU physiotherapists administered 2,192 out-of-hours cardiorespiratory physiotherapy treatments (n=685 patients) outside the ICU. Most referrals originated from the emergency department (25%), the cardiopulmonary transplant unit (20%), and the pulmonology department (16%). Referrals were from a physiotherapist in 49% of cases, from a nurse in 32%, and from a physician in 19%. Of these, 89% were made between 4:00 p.m. and 8:00 a.m., and sputum retention was the most frequent reason (86%). Conclusion: Although proving its cost effectiveness is difficult, organizing a 24-hours-per-day, 7-days-per-week cardiorespiratory physiotherapy service in a large hospital is feasible.
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Affiliation(s)
- Marianne Devroey
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium
| | - Catherine Buyse
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium
| | - Michelle Norrenberg
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium
| | - Anne-Marie Ros
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Belgium
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Huibers L, Moth G, Carlsen AH, Christensen MB, Vedsted P. Telephone triage by GPs in out-of-hours primary care in Denmark: a prospective observational study of efficiency and relevance. Br J Gen Pract 2016; 66:e667-73. [PMID: 27432608 DOI: 10.3399/bjgp16X686545] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 05/10/2016] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND In the UK, telephone triage in out-of-hours primary care is mostly managed by nurses, whereas GPs perform triage in Denmark. AIM To describe telephone contacts triaged to face-to-face contacts, GP-assessed relevance, and factors associated with triage to face-to-face contact. DESIGN AND SETTING A prospective observational study in Danish out-of-hours primary care, conducted from June 2010 to May 2011. METHOD Information on patients was collected from the electronic patient administration system and GPs completed electronic questionnaires about the contacts. The GPs conducting the face-to-face contacts assessed relevance of the triage to face-to-face contacts. The authors performed binomial regression analyses, calculating relative risk (RR) and 95% confidence intervals. RESULTS In total, 59.2% of calls ended with a telephone consultation. Factors associated with triage to a face-to-face contact were: patient age >40 years (40-64: RR = 1.13; >64: RR = 1.34), persisting problem for 12-24 hours (RR = 1.15), severe problem (RR = 2.60), potentially severe problem (RR = 5.81), and non-severe problem (RR = 2.23). Face-to-face contacts were assessed as irrelevant for 12.7% of clinic consultations and 11.7% of home visits. A statistically significantly higher risk of irrelevant face-to-face contact was found for a persisting problem of >24 hours (RR = 1.25), contact on weekday nights (RR = 1.25), and contact <2 hours before the patient's own GP's opening time (RR = 1.80). CONCLUSION Around 12% of all face-to-face consultations in the study are assessed as irrelevant by GP colleagues, suggesting that GP triage is efficient. Knowledge of the factors influencing triage can provide better education for GPs, but future studies are needed to investigate other quality aspects of GP telephone triage.
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Schols AMR, Stevens F, Zeijen CGIP, Dinant GJ, van Vugt C, Cals JWL. Access to diagnostic tests during GP out-of-hours care: A cross-sectional study of all GP out-of-hours services in the Netherlands. Eur J Gen Pract 2016; 22:176-81. [PMID: 27362282 DOI: 10.1080/13814788.2016.1189528] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND In general practice, excluding serious conditions is one of the cornerstones of the consultation. Diagnostic tests are widely used to assist the decision-making process in these cases. Little is known about general practitioners' (GPs) access to diagnostic tests at GP out-of-hours services. OBJECTIVES To determine GPs' access to diagnostic tests-imaging, function tests, laboratory tests, and point-of-care tests (POCT)-during GP out-of-hours care and to assess whether access to diagnostic facilities differs between services located adjacent to or separate from an accident and emergency (A&E) department. METHODS Cross-sectional survey of all 117 GP out-of-hours services in the Netherlands in 2014. RESULTS One-hundred-seventeen GP out-of-hours services participated in the survey; response rate 100%. Access to diagnostic tests during GP out-of-hours care varied across services, although generally there was limited access. Electrocardiography was available in 26% (30/117) of all services, conventional radiography in 19% (22/117), laboratory tests between 37% (43/117) and 65% (76/117). All services had glucose POCT and urine dipstick tests available while none utilized troponin POCT. We observed no relevant differences in access to diagnostic tests between services adjacent to or separate from an A&E department. CONCLUSION GPs in the Netherlands had limited and varying access to diagnostic tests during GP out-of-hours care in 2014. Out-of-hours services adjacent to A&E departments do not offer wider access to diagnostic tests. Further research on the accessibility of diagnostic tests in other European countries with similar and different GP out-of-hours care systems could shed further light on the effects of accessibility to diagnostic tests. [Box: see text].
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Affiliation(s)
- Angel M R Schols
- a Department of Family Medicine, School for Public Health and Primary Care (CAPHRI) , Maastricht University , the Netherlands
| | - Femke Stevens
- a Department of Family Medicine, School for Public Health and Primary Care (CAPHRI) , Maastricht University , the Netherlands
| | - Camiel G I P Zeijen
- a Department of Family Medicine, School for Public Health and Primary Care (CAPHRI) , Maastricht University , the Netherlands
| | - Geert-Jan Dinant
- a Department of Family Medicine, School for Public Health and Primary Care (CAPHRI) , Maastricht University , the Netherlands
| | | | - Jochen W L Cals
- a Department of Family Medicine, School for Public Health and Primary Care (CAPHRI) , Maastricht University , the Netherlands
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McAteer A, Hannaford PC, Heaney D, Ritchie LD, Elliott AM. Investigating the public's use of Scotland's primary care telephone advice service (NHS 24): a population-based cross-sectional study. Br J Gen Pract 2016; 66:e337-46. [PMID: 26965029 DOI: 10.3399/bjgp16X684409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/03/2015] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND There has been no comprehensive examination of the public's understanding of, and attitudes towards, NHS 24. AIM To investigate the public's use of NHS 24 and explore their understanding of, and beliefs about, the service. DESIGN AND SETTING Population-based cross-sectional study of adults in Scotland. METHOD Quantitative data were collected by self-completion postal questionnaire and qualitative data by follow-up telephone interviews. RESULTS A corrected response rate of 34.1% (n = 1190) was obtained. More than half (51.0%, n = 601) of responders had used NHS 24. Callers were more likely to be female, have at least one child, and be aged 25-34 years. Most calls (92.4%, n = 549) were made out of hours, and 54.6% (n = 327) were made on behalf of someone else. The main reason for calling was to get advice about a new symptom (69.0%, n = 414). A total of 38.6% (n = 219) of users contacted another health professional following their call, mostly on NHS 24 advice (71.7%, n = 157). Over 80.0% (n = 449) of callers were satisfied with the service and 93.9% (n = 539) would use it again.Only 8.4% (n = 78) of responders had used the NHS 24 website and 4.6% (n = 53) the NHS inform service. The main reasons for non-use were not needing the service, a preference to see their own GP, and not knowing the telephone number. NHS 24 was mainly viewed as an out-of-hours alternative to the GP. It was not considered an appropriate service for minor symptoms. The main facilitator to use was convenience, whereas the main barrier to use was not knowing how and when to use the service. CONCLUSION Although most people who used NHS 24 were satisfied, others were unclear about how and when to use the service. Further education about the full range of services that NHS 24 offers should be considered.
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