Impact of video service failure on triage outcomes in Danish out-of-hours primary care: a register-based study across four regions

BackgroundOut-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.ObjectiveThis 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.MethodsThis 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.ResultsOf 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).ConclusionsThis 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.

BackgroundMany countries have introduced video consultations in primary care both inside and outside of office hours. Despite some relational and technical limitations, general practitioners (GPs) have reported the benefits of video use in the daytime as it provides faster and more flexible access to health care. Studies have indicated that video may be specifically valuable in out-of-hours primary care (OOH-PC), but additional information on the added value of video use is needed.ObjectiveThis study aimed to investigate triage GPs’ perspectives on video use in GP-led telephone triage in OOH-PC by exploring their reasons for choosing video use and its effect on triage outcome, the decision-making process, communication, and invested time.MethodsWe conducted a cross-sectional questionnaire study among GPs performing telephone triage in the OOH-PC service in the Central Denmark Region from September 5, 2022, until December 21, 2022. The questionnaire was integrated into the electronic patient registration system as a pop-up window appearing after every third video contact. This setup automatically linked background data on the contact, patient, and GP to the questionnaire data. We used descriptive analyses to describe reasons for and effects of video use and GP evaluation, stratified by patient age.ResultsA total of 2456 questionnaires were completed. The most frequent reasons for video use were to assess the severity (n=1951, 79.4%), to increase the probability of self-care (n=1279, 52.1%), and to achieve greater certainty in decision-making (n=810, 33%) (multiple answers were possible for reasons of video use). In 61.9% (n=1516) of contacts, the triage GPs anticipated that the contact would have resulted in a different triage outcome if video had not been used. Use of video resulted in a downgrading of severity level in 88.3% (n=1338) of cases. Triage GPs evaluated the use of video as positive in terms of their decision-making process (n=2358, 96%), communication (n=2214, 90.1%), and invested time (n=2391, 97.3%).ConclusionsTriage GPs assessed that the use of video in telephone triage did affect their triage outcome, mostly by downgrading the level of care needed. The participating triage GPs found video in OOH-PC to be of added value, particularly in communication and the decision-making process.

BackgroundTelephone 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.AimTo 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 settingA mixed-methods study with simultaneous convergent design combining descriptive statistics and thematic analysis of 180 calls to a Danish out-of-hours service.MethodThe 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.ResultsMost 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.ConclusionCallers 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.

Objective To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates. Design Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data. Setting OOH primary care of the Central Denmark Region. Subjects All patient contacts in 2014–2017. Main outcome measures GPs’ tendency to prescribe antibiotics. Excess variation (not attributable to chance). Results We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including ‘activity level’ (i.e. number of patients seen in the past hour) for clinic and telephone consultations, ‘familiarity with OOH care’ (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r 2: 0.008–0.025). Conclusion Some variation in the GPs’ tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs’ activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions. KEY POINTS Current awareness: Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care. Most important results: Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics. This variation remained even after accounting for variation attributable to chance. General practitioners’ activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.

Background Increasing demand for healthcare due to demographic changes and shortage of healthcare professionals challenges the provision of unplanned care. In Denmark, different organizational changes across all regions have been implemented to meet these challenges. This provides great potential for research on the effect of different organizational choices on the use and quality of healthcare. Thus, we aim to provide a comprehensive overview of the current organizational models for acute unplanned out-of-hours primary care (OOHPC) across the five Danish regions, incorporating key contextual factors to characterize these regional systems. Methods Nationwide cross-sectional survey study on OOHPC models in all Danish regions (North, Central, Southern, Capital, and Zealand). Survey questions covered a list of predefined topics created in the author group. One survey was completed per region. Results OOHPC models differ across regions and time of day. In the North, Central, and Southern regions from 4 PM–11 PM, general practitioner (GP) cooperatives deliver OOHPC (telephone triage, tele- and clinic consultations, and home visits). From 11 PM–8 AM, the regional emergency medical services provide OOHPC in the North (GPs/physicians, paramedics) and Central (physicians, nurses, paramedics) regions. In the Southern region, the administrative responsibility of the OOHPC lies with the emergency department, but GPs provide healthcare aided by paramedics. The Capital, Central (nights), and Zealand regions have nurses and physicians performing telephone triage. All regions provide clinic consultations with physicians. In the Capital region, these consultations are hospital-based. Currently, no OOHPC data is transferred to national registries in four regions during nighttime. Conclusion Danish OOHPC models differ substantially regarding the use of healthcare professionals for delivering acute unplanned care. All regions still provide gatekeeping, where OOHPC performs a primary evaluation before a possible hospital contact. Delivery of relevant data to registries has decreased substantially with the current models, potentially creating a barrier for nationwide research on OOHPC.

Objective: General practitioners are the first point of contact in Danish out-of-hours (OOH) primary care. The large number of contacts implies that prescribing behaviour may have considerable impact on health-care expenditures and quality of care. The aim of this study was to examine the prevailing practices for medication prescription in Danish OOH with a particular focus on patient characteristics and contact type.Design and setting: A one-year population-based retrospective observational study was performed of all contacts to OOH primary care in the Central Denmark Region using registry data.Main outcome measures: Prescriptions were categorised according to Anatomical Therapeutic Chemical Classification (ATC) codes and stratified for patient age, gender and contact type (telephone consultation, clinic consultation or home visit). Prescription rates were calculated as number of prescriptions per 100 contacts.Results: Of 644,777 contacts, 154,668 (24.0%) involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits. Around 53% of all drug prescriptions were made in telephone consultations. Anti-infective medications for systemic use accounted for 45.5% of all prescriptions and were the most frequently prescribed drug group for all contact types, although accounting for less than 1/3 of telephone prescriptions. Other frequently prescribed drugs were ophthalmological anti-infectives (10.5%), NSAIDs (6.4%), opioids (3.9%), adrenergic inhalants (3.0%) and antihistamines (2.3%).Conclusion: About 25% of all OOH contacts involved one or more medication prescriptions. The highest prescription rate was found for clinic consultations, but more than half of all prescriptions were made by telephone.KEY POINTSAs the out-of-hours (OOH) primary care services cover more than 75% of all hours during a normal week, insight into the extent and type of OOH drug prescription is important.General practitioners (GPs) are responsible for more than 80% of all drug prescriptions in Denmark.Of all contacts 24.0% involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits.Of all prescriptions, 53% were made in telephone consultations.Anti-infective medications for systemic use accounted for 45.5% of all prescriptions, thereby being the most frequently prescribed drug group for all three contact types.

Background Out-of-hours primary care (OOH-PC) is facing increasing demands and workload with many negative consequences, including longer waiting time and increased risk of treatment delay and safety incidents. During the COVID-19 pandemic, video consultation (VC) was introduced as an alternative to face-to-face contact. We hypothesize that VC contributes to sustainable OOH-PC by changing patient flows, decreasing workload, and reducing waiting time. Objective This study aims to evaluate the use of video in telephone triage in OOH-PC by studying user rate, the effect on contact patterns, and patient characteristics related to receiving a VC. Methods We conducted a register-based study of VC use in OOH-PC, including all Danish residents contacting OOH-PC in the regions of Central Denmark, Southern Denmark, Northern Denmark, and Zealand. The study population will be followed from birth, immigration, or March 1, 2020 (whichever came last), until death, emigration, or December 31, 2021 (whichever comes first). We will use national registers, linking data with the unique personal identification number. We plan to conduct descriptive analyses, calculating the proportion of VC of all teletriage consultations per month during the study period. We plan to use regression models to measure the association between VC and triage outcome and the association between VC and patient characteristics, calculating risk ratios and 95% CIs. Both crude and mutual adjusted risk ratios for patient characteristics will be presented. Results Data analyses started in May 2022. Conclusions A preliminary conclusion will be presented at the conference. Conflicts of Interest None declared.

Background Antibiotic prescription rates can be affected by pandemic measures such as lockdowns, social distancing, and remote consultations in general practice. Therefore, such emergency states may negatively affect antimicrobial stewardship, specifically in out-of-hours (OOH) primary care. As contact patterns changed in the COVID-19 pandemic, it would be relevant to explore the impact on antimicrobial stewardship. Aim To study the impact of the pandemic on antibiotic prescription rates in OOH primary care, overall and per age group. Methods This cross-sectional register-based study used routine data from OOH primary care in the Central Denmark Region. We included all patient contacts in two equivalent time periods: pre-pandemic and pandemic period. The main outcome measure was defined as the number of antibiotic prescriptions per contact (antibiotic prescription rate). Results The overall antibiotic prescription rate decreased during the first year of the pandemic compared to the pre-pandemic period (RR = 0.97, 95%CI: 0.96–0.98). Likewise, the rate decreased for clinic consultations (RR = 0.63, 95%CI: 0.62–0.64). However, an increase was seen for telephone consultations (RR = 1.73, 95%CI: 1.70–1.76). The decline in clinic consultations was largest for consultations involving children aged 0–10 years (RR = 0.53, 95%CI: 0.51–0.56). Conclusion Antibiotic prescription rates in Danish OOH primary care decreased during the first year of the COVID-19 pandemic, especially for young children. Prescription rates decreased in clinic consultations, whereas the rates increased in telephone consultations. Further research should explore if antibiotic prescription rates have returned to pre-pandemic levels, and if the introduction of video consultations has affected antibiotic prescription patterns in OOH primary care.

IntroductionThe two-week wait (TWW) pathway for suspected upper gastrointestinal (UGI) cancer is a straight to test (STT) approach. Due to the COVID-19 pandemic, national guidance recommended cessation of all endoscopy...

Multidisciplinary team puts the ‘home’ in hospital-to-home

Objective To investigate the correlation between having designated general practitioners (GPs) in residential care homes and the residents’ number of contacts with primary care, number of hospital admissions and mortality. Design A retrospective register-based longitudinal study. Setting Forty-two care homes in Aarhus Municipality, Denmark. Subjects A total of 2376 care home residents in the period from 1 September 2016 to 31 December 2018. Main outcome measures We used two models to calculate the incidence risk ratio (IRR) for primary care contacts, hospital admission or dying. Model 1 compared the residents’ risk time before with their risk time after implementation of the designated GP model. Model 2 included only risk time after implementation and was based on calculations of successful (rate ≥60%) implementation. Results Weighted by time at risk, the proportion of females across the two models ranged from 64% to 68%. The largest group was aged ‘85-94’ years. In Model 1, the mere implementation of the model did not correlate with changes in primary care contacts, hospital admissions, or mortality. Contrarily, in Model 2, residents living in care homes with successful implementation had fewer email contacts (IRR = 0.81, 95%CI: 0.68;0.96), fewer telephone contacts (IRR = 0.78, 95%CI: 0.68;0.90) and fewer hospital admissions (IRR = 0.85, 95%CI: 0.73;0.99), but more home visits (IRR = 1.70, 95%CI: 1.29;2.25) than residents living in care homes with lower implementation rates. Conclusion The designated GP model seems promising, as a high implementation degree of the model correlated with a reduced the number of acute admissions, short-term admissions and readmissions. Future studies should focus on gaining deeper insight into the mechanisms of the designated GP model to further optimize the model. Key points A new care model was introduced in Denmark in 2017, designating dedicated GPs to residential care homes for the elderly. Successful implementation correlated with significantly fewer hospital admissions, specifically for acute admissions, but also with fewer short-term admissions and readmissions. The implementation of the model correlated significantly with fewer e-mail and telephone contacts and with more home visits. Future studies should gain more insight into the mechanisms of the designated GP model to further optimize the model.

BackgroundLow patient satisfaction with the quality of out-of-hours primary care (OOH-PC) has been linked with several individual and organizational factors. However, findings have been ambiguous and may not apply to the Danish out-of-hours (OOH) setting in which general practitioners (GPs) perform the initial telephone triage. This study aimed to identify patient-related, GP-related and organizational factors associated with low patient satisfaction.MethodsThe study was based on data from a 1-year population-based survey of OOH-PC (LV-KOS) in the Central Denmark Region in 2010–2011. GPs on OOH duty completed an electronic questionnaire in the OOH computer system, and the registered patients received a subsequent postal questionnaire focusing on contact evaluation, waiting time, demographic characteristics and general self-perceived health. Associations were analysed using multivariable logistic regression with dissatisfaction as the dependent variable.ResultsThe patient response rate was 50.6%. For all contact types, 82.5% of the patients were satisfied with the OOH-PC service. More patients were dissatisfied with telephone consultations than with clinic consultations or home visits (8.5% vs. 6.0% and 4.3%, respectively). Contacts assessed by the GP as ‘not severe’ were associated with dissatisfaction for telephone consultations and home visits. Poor general self-perceived health was associated with dissatisfaction for all contact types. Living in urban areas was associated with dissatisfaction for telephone consultations, while unacceptable waiting time was associated with dissatisfaction for all contact types.ConclusionsWe found a high level of patient satisfaction with the OOH-PC service. The only factors affecting patient satisfaction across all contact types were unacceptable waiting time and poor general self-perceived health. For the other investigated factors, patient satisfaction depended on the type of contact. Generally, patients contacting for GP-assessed non-severe health problem and patients living in urban areas were more dissatisfied.

Background Telephone triage is a service innovation in which every patient asking to see a general practitioner or other primary care professional calls the general practice and usually speaks to a receptionist first, who records a few details. The patient is then telephoned back by the general practitioner/primary care professional. At the end of this return telephone call with the general practitioner/primary care professional, either the issue is resolved or a face-to-face appointment is arranged. Before the COVID-19 pandemic, telephone triage was designed and used in the UK as a tool for managing demand and to help general practitioners organise their workload. During the first quarter of 2020, much of general practice moved to a remote (largely telephone) triage approach to reduce practice footfall and minimise the risk of COVID-19 contact for patients and staff. Ensuring equitable care for people living with multiple long-term health conditions (‘multimorbidity’) is a health policy priority. Objective We aimed to evaluate whether or not the increased use of telephone triage would affect access to primary care differently for people living with multimorbidity than for other patients. Methods We used data from the English GP Patient Survey to explore the inequalities impact of introducing telephone triage in 154 general practices in England between 2011 and 2017. We looked particularly at the time taken to see or speak to a general practitioner for people with multiple long-term health conditions compared with other patients before the COVID-19 pandemic. We also used data from Understanding Society, a nationally representative survey of households from the UK, to explore inequalities in access to primary care during the COVID-19 pandemic (between April and November 2020). Results Using data from before the COVID-19 pandemic, we found no evidence (p = 0.26) that the impact of a general practice moving to a telephone triage approach on the time taken to see or speak to a general practitioner was different for people with multimorbidity and for people without. During the COVID-19 pandemic, we found that people with multimorbidity were more likely than people with no long-term health conditions to have a problem for which they needed access to primary care. Among people who had a problem for which they would normally try to contact their general practitioner, there was no evidence of variation based on the number of conditions as to whether or not someone did try to contact their general practitioner; whether or not they were able to make an appointment; or whether they were offered a face-to-face, an online or an in-person appointment. Limitations Survey non-response, limitations of the specific survey measures of primary care access that were used, and being unable to fully explore the quality of the telephone triage and consultations were all limitations. Conclusions These results highlight that, although people with multimorbidity have a greater need for primary care than people without multimorbidity, the overall impact for patients of changing to a telephone triage approach is larger than the inequalities in primary care access that exist between groups of patients. Future work Future evaluations of service innovations and the ongoing changes in primary care access should consider the inequalities impact of their introduction, including for people with multimorbidity. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 18. See the NIHR Journals Library website for further project information.

Objectives:One purpose of electronic reminders is improvement of the quality of documentation in office-hours primary care. The aim of this study was to evaluate how implementation of electronic reminders alters the rate and/or content of diagnostic data recorded by primary care physicians in office-hours practices in primary care health centers.Methods:The present work is a register-based longitudinal follow-up study with a before-and-after design. An electronic reminder was installed in the electronic health record system of the primary health care of a Finnish city to remind physicians to include the diagnosis code of the visit in the health record. The report generator of the electronic health record system provided monthly figures for the number of various recorded diagnoses by using the International Classification of Diseases, 10th edition, and the total number of visits to primary care physicians, thus allowing the calculation of the recording rate of diagnoses on a monthly basis. The distribution of diagnoses before and after implementing ERs was also compared.Results:After the introduction of the electronic reminder, the rate of diagnosis recording by primary care physicians increased clearly from 39.7% to 87.2% (p < 0.001). The intervention enhanced the recording rate of symptomatic diagnoses (group R) and some chronic diseases such as hypertension, type 2 diabetes and other soft tissue disorders. Recording rate of diagnoses related to diseases of the respiratory system (group J), injuries, poisoning and certain other consequences of external causes (group S), and diseases of single body region of the musculoskeletal system and connective tissue (group M) decreased after the implementation of electronic reminders.Conclusion:Electronic reminders may alter the contents and extent of recorded diagnosis data in office-hours practices of the primary care health centers. They were found to have an influence on the recording rates of diagnoses related to chronic diseases. Electronic reminders may be a useful tool in primary health care when attempting to change the behavior of primary care physicians.

GPs can use video when performing telephone triage in out-of-hours primary care (OOH-PC) in Denmark. Video use varies considerably among GPs; this variation could be related to GP characteristics. To investigate associations between GP characteristics and video use in OOH-PC telephone triage. A register-based study using data from the OOH-PC registration system from 1 January 2021 to 31 December 2021. Binomial regression analysis was used to measure the associations between video contacts and triage GP characteristics, thereby calculating risk ratios (RRs) and 95% confidence intervals (CI). Video was used in 10.8% of telephone triage contacts to OOH-PC. Video use was significantly associated with GPs having more shifts in OOH-PC (RR: 1.36-1.93, reference: low number of shifts) and GPs being younger (RR: 0.84-0.67, reference: age<40 years). Central Denmark Region and Region of Southern Denmark had significant higher video-user rates (RR: 1.23-1.46) than North Denmark Region, whereas Region Zealand had significant lower rates (RR = 0.57, 95% confidence interval [CI] = 0.38 to 0.87). The association between video use and GP sex was modified by number of shifts in OOH-PC. Video use was positively correlated with male sex among GPs with low, medium, and high number of shifts (RR = 1.18, 95% CI = 1.07 to 1.29) and negatively correlated with male sex among GPs with very high number of shifts (RR = 0.75, 95% CI = 0.58 to 0.98). Video use was associated with the number of shifts in OOH-PC, GP sex and age, and geographical region.