Linda Huibers

Out-of-hours care in western countries: assessment of different organizational models.

BackgroundInternationally, different organizational models are used for providing out-of-hours care. The aim of this study was to assess prevailing models in order to identify their potential strengths and weaknesses.MethodsAn international web-based survey was done in 2007 in a sample of purposefully selected key informants from 25 western countries. The questions concerned prevailing organizational models for out-of-hours care, the most dominant model in each country, perceived weaknesses, and national plans for changes in out-of-hours care.ResultsA total of 71 key informants from 25 countries provided answers. In most countries several different models existed alongside each other. The Accident and Emergency department was the organizational model most frequently used. Perceived weaknesses of this model concerned the coordination and continuity of care, its efficiency and accessibility. In about a third of the countries, the rota group was the most dominant organizational model for out-of-hours care. A perceived weakness of this model was lowered job satisfaction of physicians. The GP cooperative existed in a majority of the participating countries; no weaknesses were mentioned with respect to this model. Most of the countries had plans to change the out-of-hours care, mainly toward large scale organizations.ConclusionGP cooperatives combine size of scale advantages with organizational features of strong primary care, such as high accessibility, continuity and coordination of care. While specific patients require other organizational models, the co-existence of different organizational models for out-of-hours care in a country may be less efficient for health systems.

Quality of after-hours primary care in the Netherlands: a narrative review.

Many Western countries are seeking an organizational model for after-hours primary care that is safe, efficient, and satisfactory for patients and health care professionals. Around the year 2000, Dutch primary care physicians (PCPs) reorganized their after-hours primary care and shifted from small rotation groups to large-scale PCP cooperatives. This article provides a narrative review of studies on a range of issues about after-hours primary care in the Netherlands, including experiences of health care professionals and patients, patient-safety incidents, adherence to practice guidelines, waiting times, and quality of telephone triage. Physicians expressed high satisfaction with PCP cooperatives; their workload decreased, and job satisfaction increased compared with the situation before the reorganization. In general, patients were also satisfied, but areas for improvement included telephone consultations, patient education, and distance to a pharmacy. A study identified patient-safety incidents in 2.4% of all contacts, of which most did not result in harm to patients. The average adherence to clinical guidelines by physicians was 77%, with lowest adherence scores for prescribing antibiotics and treatment in emergency cases. The average waiting time for home visits was 30 minutes. Seventy percent of patients with life-threatening problems were visited within the time target of 15 minutes. Telephone triage by nurses had positive effects on care efficiency by increasing the proportion of telephone consultations and decreasing the proportion of clinic consultations and home visits. The after-hours primary care system in the Netherlands might set an example for other countries struggling to find a good solution for the problems they encounter with after-hours primary care. Future developments in the Netherlands include integration and extensive collaboration with the accident and emergency departments of hospitals, in which PCPs take care of self-referring patients.

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

Objective.Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care. Methods. A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem). Results. Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5–97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7–90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7–49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6). Conclusions. There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.

Validity of telephone and physical triage in emergency care: The Netherlands Triage System

BACKGROUND Due to emergency care overcrowding, right care at the right place and time is necessary. Uniform triage of patients contacting different emergency care settings will improve quality of care and communication between health care providers. OBJECTIVE Validation of the computer-based Netherlands Triage System (NTS) developed for physical triage at emergency departments (EDs) and telephone triage at general practitioner cooperatives (GPCs). METHODS Prospective observational study with patients attending the ED of a university-affiliated hospital (September 2008 to November 2008) or contacting an urban GPC (December 2008 to February 2009). For validation of the NTS, we defined surrogate urgency markers as best proxies for true urgency. For physical triage (ED): resource use, hospitalization and follow-up. For telephone triage (GPC): referral to ED, self-care advice after telephone consultation or GP advice after physical consultation. Associations between NTS urgency levels and surrogate urgency markers were evaluated using chi-square tests for trend. RESULTS We included nearly 10 000 patients. For physical triage at ED, NTS urgency levels were associated with resource use, hospitalization and follow-up. For telephone triage at GPC, trends towards more ED referrals in high NTS urgency levels and more self-care advices after telephone consultation in lower NTS urgency levels were found. The association between NTS urgency classification and GP advice was less explicit. Similar results were found for children; however, we found no association between NTS urgency level and GP advice. CONCLUSIONS Physically and telephone-assigned NTS urgency levels were associated with majority of surrogate urgency markers. The NTS as single triage system for physical and telephone triage seems feasible.

Patient safety in out-of-hours primary care: a review of patient records

BackgroundMost patients receive healthcare in primary care settings, but relatively little is known about patient safety. Out-of-hours contacts are of particular importance to patient safety. Our aim was to examine the incidence, types, causes, and consequences of patient safety incidents at general practice cooperatives for out-of-hours primary care and to examine which factors were associated with the occurrence of patient safety incidents.MethodsA retrospective study of 1,145 medical records concerning patient contacts with four general practice cooperatives. Reviewers identified records with evidence of a potential patient safety incident; a physician panel determined whether a patient safety incident had indeed occurred. In addition, the panel determined the type, causes, and consequences of the incidents. Factors associated with incidents were examined in a random coefficient logistic regression analysis.ResultsIn 1,145 patient records, 27 patient safety incidents were identified, an incident rate of 2.4% (95% CI: 1.5% to 3.2%). The most frequent incident type was treatment (56%). All incidents had at least partly been caused by failures in clinical reasoning. The majority of incidents did not result in patient harm (70%). Eight incidents had consequences for the patient, such as additional interventions or hospitalisation. The panel assessed that most incidents were unlikely to result in patient harm in the long term (89%). Logistic regression analysis showed that age was significantly related to incident occurrence: the likelihood of an incident increased with 1.03 for each year increase in age (95% CI: 1.01 to 1.04).ConclusionPatient safety incidents occur in out-of-hours primary care, but most do not result in harm to patients. As clinical reasoning played an important part in these incidents, a better understanding of clinical reasoning and guideline adherence at GP cooperatives could contribute to patient safety.

EurOOHnet—the European research network for out-of-hours primary health care

Abstract Background and rationale: European countries face similar challenges in the provision of health care. Demographic factors like ageing, population growth, changing patient behaviour, and lack of work force lead to increasing demands, costs, and overcrowding of out-of-hours (OOH) care (i.e. primary care services, emergency departments (EDs), and ambulance services). These developments strain services and imply safety risks. In the last few decades, countries have been re-organizing their OOH primary health care services. Aim and scope of the network: We established a European research network for out-of-hours primary health care (EurOOHnet), which aims to transfer knowledge, share experiences, and conduct research. Combining research competencies and integrating results can generate a profound information flow to European researchers and decision makers in health policy, contributing towards feasible and high-quality OOH care. It also contributes to a more comparable performance level within European regions. Conducted research projects: The European research network aims to conduct mutual research projects. At present, three projects have been accomplished, among others concerning the diagnostic scope in OOH primary care services and guideline adherence for diagnosis and treatment of cystitis in OOH primary care. The future: Future areas of research will be organizational models for OOH care; appropriate use of the OOH services; quality of telephone triage; quality of medical care; patient safety issues; use of auxiliary personnel; collaboration with EDs and ambulance care; and the role of GPs in OOH care.

GP cooperative and emergency department: an exploration of patient flows

RATIONALE, AIMS AND OBJECTIVES In most countries, different health care providers are involved in emergency care. In the Netherlands, out-of-hours care is provided by general practitioner cooperatives (GPCs) and emergency departments (EDs). Our aim was to describe the flow of patients attending emergency care in these settings. METHOD A retrospective record review was performed, concerning patients who had visited a GPC or ED. Recorded information included urgency, diagnostic tests, and follow-up contacts. Descriptive figures were determined for patient flows in GPC and ED for urgent contacts and non-urgent contacts. RESULTS We included 319 GPC contacts and 356 ED contacts, of which 78% were non-urgent. The majority of GPC contacts were completed at the GPC without follow-up; 37% of non-urgent patients had a follow-up contact, usually with primary care. Only 5% of non-urgent GPC patients received diagnostic tests compared to 63% of non-urgent ED patients (mostly X-rays). The majority of non-urgent ED patients (88%) had a follow-up contact, usually at an outpatient clinic (67%). Most non-urgent ED patients (83%) who received a diagnostic test also had an outpatient clinic follow-up contact. Of urgent ED patients, the majority had a follow-up contact (85%), mostly with an outpatient clinic (74%). CONCLUSION Although most out-of-hours care patients present non-urgent health problems, at the ED they are more likely to receive diagnostic tests and follow-up contacts. This may reflect differences in patient populations between the ED and GPC or suggest opportunities for improving efficiency of planning follow-up contacts.

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

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

Antibiotic prescribing patterns in out-of-hours primary care: A population-based descriptive study

Abstract Objective. To describe the frequency and characteristics of antibiotic prescribing for different types of contacts with the Danish out-of-hours (OOH) primary care service. Design. Population-based observational registry study using routine registry data from the OOH registration system on patient contacts and ATC-coded prescriptions. Setting. The OOH primary care service in the Central Denmark Region. Subjects. All contacts with OOH primary care during a 12-month period (June 2010–May 2011). Main outcome measures. Descriptive analyses of antibiotic prescription proportions stratified for type of antibiotic, patient age and gender, contact type, and weekdays or weekend. Results. Of the 644 777 contacts registered during the study period, 15.0% received an antibiotic prescription: 26.1% resulted from clinic consultations, 10.7% from telephone consultations, and 10.9% from home visits. The prescription proportion was higher for weekends (17.6%) than for weekdays (10.6%). The most frequently prescribed antibiotic drugs were beta-lactamase sensitive penicillins (34.9%), antibiotic eye drops (21.2%), and broad-spectrum penicillins (21.0%). Most antibiotic eye drops (73%) were prescribed in a telephone consultation. Most antibiotics were prescribed at 4–6 p.m. on weekdays. Young infants received most antibacterial eye drops (41.3%), patients aged 5–17 years and 18–60 years received most beta-lactamase sensitive penicillins (44.6% and 38.9%, respectively), while patients aged 60 + years received most broad-spectrum penicillins (32.9% of all antibiotic prescriptions). Conclusion. Antibiotics were most often prescribed in clinic consultations, but, in absolute terms, many were also prescribed by telephone. The high prescription proportion, particularly antibacterial eye drops for young infants, suggests room for improvement in rational antibiotic use.

Follow-up After Telephone Consultations at Out-of-Hours Primary Care

Background: After a contact with a primary care physician (PCP) cooperative for out-of-hours care, many patients have subsequent contact with health care. Little is known about the factors associated with these follow-up contacts. The objective of this study was to examine whether patient experiences with nurse telephone consultations and the cooperatives organizational characteristics were associated with the probability of follow-up contact. Methods: We conducted a cross-sectional study of patients attending 16 Dutch PCP cooperatives (2009 to 2011) using a validated questionnaire to measure patient experiences with nurse telephone consultations and patient-reported follow-up. Participating cooperatives provided information on 12 organizational characteristics. Multilevel regression modeling was used to identify associations. Results: A total of 7039 patients returned a questionnaire (50.4%), of which 5678 were complete. About half of patients reported a follow-up contact (47%). Regression analyses showed increasing probability of follow-up contact in patients with higher age (≥65 years; odds ratio [OR], 2.39), patients receiving a home visit (OR, 1.32), and cooperatives with a higher percentage of telephone consultations (OR, 1.02) and a decreased probability among patients with more positive experiences with a nurse via telephone contact (OR, 0.68). Conclusion: Although follow-up contacts can be medically required, a substantial number of contacts seem to be not required and thus are potentially avoidable (eg, by changes in work routine and communication).