After-hours Services Research Articles

What matters to people with chronic conditions when accessing care in Australian general practice? A qualitative study of patient, carer, and provider perspectives

BackgroundResearch underpinning the patient experience of people with chronic conditions in Australian general practice is not well developed. We aimed to ascertain the perspectives of key stakeholders on aspects of patient experience, more specifically with regards to accessing general practice in Australia.MethodsUsing a qualitative design, semi-structured interviews were conducted by telephone and face-to-face with people living with one or more chronic conditions, informal carers, and primary care providers between October 2016 and October 2017. Participants were recruited and selected from three demographically representative primary health networks across Sydney, Australia. Interview transcripts and researcher’s reflective fieldnotes were coded and analyzed for key themes of access. Analysis and interpretation of data were guided by Levesque’s model of access, a conceptual framework to evaluate access broadly and from corresponding patient- and provider-side dimensions.ResultsA total of 40 interviews were included in the analysis. Most participants had attended their general practices for 10 years or more and had regular primary care providers. People with chronic conditions reported access barriers predominantly in their ability to reach services, which were related to illness-related disabilities (limited mobility, chronic pain, fatigue, frailty) and limitations in the availability and accommodation of health services to address patient preferences (unavailability of after-hours services, lack of alternative modes of service delivery). While cost was not a major barrier, we found a lack of clarity in the factors that determined providers’ decisions to waive or reduce costs for some patients and not others.ConclusionsPeople managing chronic conditions with a long-term primary care provider experienced access barriers in general practice, particularly in their ability to physically reach care and to do so on a timely basis. This study has important policy and practice implications, as it highlights patients’ experiences of accessing care and possible areas for improvement to appropriately respond to these experiences. Themes identified may be useful in the design of a patient experience survey tool specific to this population. While it incorporates perspectives from patients, carers and providers, this study could be further strengthened by including perspectives from culturally and linguistically underrepresented patient groups and more carers.

Widespread emergency department access block: a human rights issue in Australia?

There are increasing demands on emergency psychiatrists with higher numbers of mental health presentations, and longer stays in emergency departments (EDs). Australia, like other English speaking countries, funds considerably lower numbers of psychiatric beds than average for Organisation for Economic Co-operation and Development (OECD) countries. Consequently, acute bed occupancy is high, and a bed is frequently unavailable when a person needs admission. Patients with serious mental illness can wait days in busy and overstimulating EDs, become agitated and assaultive, and then require chemical and physical restraint. All patients have a right to safe high quality care, but the paucity of beds deprives patients of this right. The Australasian College of Emergency Medicine recommends reporting ED access block to health ministers, and human rights and/or health rights commissioners, and recommends increased funding for inpatient psychiatric care, emergency mental health and after-hours community services, together with more alcohol and other drug programs. It is challenging for emergency physicians and psychiatrists to provide optimal care for acutely unwell patients who stay extended periods in the ED. Increasing the availability of inpatient care must be considered as part of a comprehensive solution for minimising ED lengths of stay in Australia.

Context matters for primary health care access: a multi-method comparative study of contextual influences on health service access arrangements across models of primary health care

BackgroundEquitable access to primary health care (PHC) is an important component of integrated chronic disease management. Whilst context is known to influence access to PHC, it is poorly researched. The aim of this study was to determine the contextual influences associated with access arrangements in four Australian models of integrated PHC.MethodsA multi-method comparative case study design. Purposive sampling identified four models of PHC across six sites in two Australian states. Complexity theory informed the choice of contextual factors that influenced access arrangements, which were analysed across five dimensions: availability and accommodation, affordability, acceptability, appropriateness and approachability. Semi-structured interviews, document/website analysis and non-participant observation were used to collect data from clinicians, administrative staff and other key stakeholders. Within and cross-case thematic analysis identified interactions between context and access across sites.ResultsOverall, financial viability, objectives of the PHC model and relationships with the local hospital network (LHN) underpinned access arrangements. Local supply of general practitioners and financial viability were strong influences on availability of after-hours services. Influences on affordability were difficult to determine because all models had nil/low out-of-pocket costs for general practitioner services. The biggest influence on acceptability was the goal/objectives of the PHC model. Appropriateness and to a lesser degree affordability arrangements were influenced by the relationship with the LHN. The provision of regular outreach services was strongly influenced by perceived population need, referral networks and model objectives.ConclusionsThese findings provide valuable insights for policy makers charged with improving access arrangements in PHC services. A financially sustainable service underpins attempts to improve access that meets the needs of the service population. Smaller services may lack infrastructure and capacity, suggesting there may be a minimum size for enhancing access. Access arrangements may be facilitated by aligning the objectives between PHC, LHN and other stakeholder models. While some access arrangements are relatively easy to modify, improving resource intensive (e.g. acceptability) access arrangements for vulnerable and/or chronic disease populations will require federal and state policy levers with input from primary health networks and LHNs.

Supplier-induced demand for urgent after-hours primary care services.

Australia is one of nine Organisation for Economic Co-operation and Development (OECD) countries that utilise deputising services to provide after-hours primary care. While the provision of this service is supposed to be on behalf of regular general practitioners, businesses have adapted to the financial incentives on offer and are directly advertising their services to consumers emphasising patient convenience and no copayments. The introduction of corporate entities has changed the way that deputising services operate. We use a difference-in-difference approach to estimate the amount of growth in urgent after-hours services that was not warranted by urgent medical need. These estimates are calculated by comparing the growth in urgent attendances that occurred during times of the day that are classified as "after-hours" (e.g., 6pm-11pm Monday to Friday) with those that are classified as "unsociable-hours" (e.g., 11pm-7am Monday to Friday). For the national level, we estimate that 593,141 unwarranted attendances were induced as urgent after-hours consultations in a single year. This corresponds to a national estimate of the total benefits paid for unwarranted demand of approximately $77 million. While deputising services have filled a short-fall in after-hours services, the overuse of urgent items has meant that that this has been achieved at a considerable cost to the Australian Government.

Reaching key adolescent populations.

Adolescents and young people who fit within key populations face some of the greatest barriers to HIV care, but are frequently overlooked. We review the recent literature on these young, vulnerable populations including HIV risk factors, barriers to care, and strategies for engagement. Common risk factors include age, risky sexual practices, poor education, and high levels of alcohol and drug abuse. Barriers to care include limited data, criminalization, and high levels of stigma. Strategies to increase engagement include incorporating adolescents into biological and behavioral surveys and the use of social media. Digital innovations for HIV prevention and testing show promise, and pre-exposure prophylaxis may be acceptable. At a policy level, decriminalizing same-sex activity and commercial sex work are priorities. Differentiated models of care including HIV self-testing, after-hour services, community-based delivery, and multimonth dispensing of antiretroviral therapy, should be combined into holistic care. There has been limited success in reaching these key adolescent populations largely because of criminalization and stigma. Accurate, generalizable data are needed to inform the development of innovative strategies for holistic care.

Helsinki Stroke Model Is Transferrable With "Real-World" Resources and Reduced Stroke Thrombolysis Delay to 34 min in Christchurch.

Christchurch hospital is a tertiary hospital in New Zealand supported by five general neurologists with after-hours services provided mainly by onsite non-neurology medical residents. We assessed the transferrability and impact of the Helsinki Stroke model on stroke thrombolysis door-to-needle time (DNT) in Christchurch hospital. Key components of the Helsinki Stroke model were implemented first in 2015 with introduction of patient pre-notification and thrombolysis by the computed tomography (CT) suite, followed by implementation of direct transfer to CT on ambulance stretcher in May 2017. Data from the prospective thrombolysis registry which began in 2012 were analyzed for the impact of these interventions on median DNT. Between May and December 2017, 46 patients were treated with alteplase, 25 (54%) patients were treated in-hours (08:00-17:00 non-public holiday weekdays) and 21 (46%) patients were treated after-hours. The in-hours, after-hours, and overall median (interquartile range) DNTs were 34 (28-43), 47 (38-60), and 40 (30-51) minutes. The corresponding times in 2012-2014 prior to interventions were 87 (68-106), 86 (72-116), and 87 (71-112) minutes, representing median DNT reduction of 53, 39, and 47 minutes, respectively (p-values <0.01). The interventions also resulted in significant reductions in the overall median door-to-CT time (from 49 to 19 min), CT-to-needle time (32 to 20 min) and onset-to-needle time (168 to 120 min). The Helsinki stroke model is transferrable with real-world resources and reduced stroke DNT in Christchurch by over 50%.

Continuity of care in after-hours house call medical services: An exploration of follow-up patterns in an Australian context.

This study explores the postconsultation follow-up behaviours of patients who used the Australian after-hours house-call (AHHC) medical services. These behaviours provide insights into the nature of the continuity of care (CoC) in the industry and are a measure quality in AHHC service delivery. Understanding the patterns of these CoCs and their predictors will enable stakeholders in the industry, both locally and globally, plan and implement higher quality services. This is a cross-sectional survey of all 10,838 patients who used AHHC during the last week of January 2016. A validated questionnaire was used, distributed through a mix of online and postal questionnaires. One thousand two hundred twenty-eight questionnaires were returned (11.3%). Had the AHHC not been available, 38.6% of respondents would have gone to their own general practitioners (GPs), 40.1% to an emergency department (ED), 15.9% to an office-based after-hours service, and 5.5% would have done nothing. After the AHHC visits, however, 47.3% followed up with their GPs, 8.4% went to an ED, 4.2% arranged for a further AHHC visit, while 40.0% required no follow-up. Patients who required GP follow-ups were likely to be dissatisfied with aspects of the AHHC care received, while those with no follow-ups were generally satisfied. Patients ≥65years were more likely to require no follow-ups (P<.001) and, if they did, were unlikely to do so with their GPs (P=.04). Where required, follow-ups for those aged ≤16years were likely to result in ED attendances (P=.01), while students generally rely on AHHCs for follow-ups (P=.03). Compared to females, males were likely to rely on their GPs (P=.01), and less likely to go to an ED (P=.01). Most patients seen by Australian AHHC services either end up requiring no further follow-up, or do so with their own GPs, with few relying on further AHHC visits for follow-up. The real reasons for follow-up differences observed by age and gender may need to be explored further so as to ensure that the AHHC services are better used.

Evaluation of aggression in Australian after-hours doctor home-visit services.

Minimizing the risks and distress arising from aggression in after-hours house call (AHHC) services will help improve service quality in the industry. Unfortunately, no national study has ever evaluated this in Australian AHHCs. Apart from reducing this gap, findings from this work will have global relevance given the rising popularity of the AHHC industry worldwide. A survey of all 300 doctors employed by the National Home Doctor Service, Australia's largest AHHC service provider. A validated electronic questionnaire was used to examine the doctors' experiences over a 12-month period. There were 168 valid responses (56% response rate). Aggression prevalence was 47.1%, and just over half (51.8%) of the cases came from the patients. "Verbal aggression" was the commonest (48.3%). Others are "threats" (26.6%), "vexatious complaints" (13.3%), "property damage" (4.2%), "physical violence" (4.2%), "sexual harassment" (2.8%), and "stalking" (0.7%). Majority of the respondents were concerned (90.2%) and apprehensive (75.2%) regarding the risks. Doctors who have experienced aggression were more likely to express apprehension (OR=3.99; CI=1.54-10.31; P=0.004), while those that have attained Postgraduate Fellowships (Vocationally Registered) were less likely to report experiences of aggression (OR=0.28; CI=0.09-0.84; P=0.02). Even though a higher proportion of females were concerned (92.3% vs 89.6%) and apprehensive (82.1% vs 73.6%) compared with males, these differences were not statistically significant (Fisher's Exact Tests: P=1.000 and 0.469, respectively). Aggression in Australian AHHC affects nearly 1-in-2 practitioners, with high levels of concern and apprehension being expressed. Concerned companies should do more to ensure that their doctors attain PG fellowships, as this is linked to lower reports of aggression. Where possible, family and friends need to be involved in patient care, as nearly half of the reported aggressions come from them.

After-hours respiratory physiotherapy for intubated and mechanically ventilated patients with community-acquired pneumonia: An Australian perspective.

IntroductionCommunity acquired pneumonia (CAP) is a common reason for admission to an intensive care unit for intubation and mechanical ventilation, and results in high morbidity and mortality. The primary aim of the study was to investigate availability and provision of respiratory physiotherapy, outside of normal business hours, for intubated and mechanically ventilated adults with CAP in Australian hospitals. Materials and methodsA cross-sectional, mixed methods online survey was conducted. Participants were senior intensive care unit physiotherapists from 88 public and private hospitals. Main outcome measures included presence and nature of an after-hours physiotherapy service and factors perceived to influence the need for after-hours respiratory physiotherapy intervention, when the service was available, for intubated adult patients with CAP. Data were also collected regarding respiratory intervention provided after-hours by other ICU professionals. ResultsResponse rate was 72% (n=75). An after-hours physiotherapy service was provided by n=31 (46%) hospitals and onsite after-hours physiotherapy presence was limited (22%), with a combination of onsite and on-call service reported by 19%. Treatment response (83%) was the most frequent factor for referring patients with CAP for after-hours physiotherapy intervention by the treating day-time physiotherapist. Nurses performing respiratory intervention (77%) was significantly associated with no available after-hours physiotherapy service (p=0.04). DiscussionPhysiotherapy after-hours service in Australia is limited, therefore it is common for intubated patients with CAP not to receive any respiratory physiotherapy intervention outside of normal business hours. In the absence of an after-hours physiotherapist, nurses were most likely to perform after-hours respiratory intervention to intubated patients with CAP. ConclusionFurther research is required to determine whether the frequency of respiratory physiotherapy intervention, including after-hours provision of treatment, influences outcomes for ICU patients intubated with pneumonia.

Temporal availability of obstetrics and gynecology clinics in Taiwan: A nationwide survey

ObjectiveObstetrician–gynecologists are the main providers of women's healthcare. However, workforce shortages and excessive workloads among these providers have been encountered in many countries. While most past studies on this subject have investigated the spatial distribution of obstetrics–gynecology clinics, few have focused on their temporal availability, especially on the national level. Materials and methodsThe weekly opening time schedules (divided into morning, afternoon, and evening sessions) of all obstetrics–gynecology clinics in Taiwan were extracted from the web site of Taiwan's National Health Insurance Administration in July 2015. The numbers of open sessions were then analyzed and stratified by urbanization level and practice type. ResultsAmong 742 obstetrics–gynecology clinics in Taiwan, 521 were located in urban areas, 194 in suburban areas, and 27 in rural areas. The numbers of open sessions per week in suburban areas were higher than those in urban and rural areas (16.7 ± 2.6 vs. 15.9 ± 3.1 and 15.9 ± 2.7). Group practices had more open sessions per week than solo practices (16.8 ± 2.8 vs. 15.8 ± 3.0). With respect to after-hours services in rural areas, only two rural obstetrics–gynecology clinics remained open on Sunday mornings, while none remained open on Sunday afternoons and evenings. ConclusionObstetrics–gynecology clinics in Taiwan offered great temporal availability. In addition to the remarkable urban–rural disparity in the distribution of obstetrics–gynecology clinics, the availability of services on Sundays in rural areas demands special attention.

Patient-reported impact of after-hours house-call services on the utilization of emergency department services in Australia.

This paper explores, from the patients' perspective, the likely impact of the Australian after-hours house-call (AHHC) medical services on emergency department (ED) presentations. This has become imperative given the significant cost difference between patient presentations to either the AHHC or ED and their practical implications for health care funding. A cross-sectional, self-reported survey of all 10 838 patients in Australia known to have patronized AHHC services over the last week of January 2016. The study used a validated, self-completion questionnaire, dispatched through a mixture of online and postal methods. A total of 1228 questionnaires were returned, of which 1211 included all relevant sections of the survey (11.2% response rate). Four hundred and eighty-six patients (40.1%) indicated that they would have gone to the ED on the same day or night of their illness had the AHHC not been available, with the elderly (≥65) and children (<16) accounting for nearly two-thirds of these (64.6%). Following their AHHC consultations, 103 (8.5%) patients eventually attended the ED, meaning that the service prevented 383 patients from attending the ED, a decrease of 78.8%. Stratification based on location showed that this impact was seen across all states and territories in Australia where AHHC services exist, ranging from a reduction of 73.9% in Western Australia to 85.0% in Tasmania. Similarly, the impact cuts across all patient demographics, including age ranges, gender and social divides. Based on our respondents' reports, AHHC services appear to be associated with a reduction in ED visits in Australia, with the impact cutting across all regions and patient demographics.

The determinants and engagement patterns of chaperones and chauffeurs by Australian doctors in after-hours house-call services.

ObjectivesThe use of escorts (chauffeurs and chaperones) while on duty in after-hours-house-call (AHHC) is one key protective option available to doctors in the service, and has been linked to low burnout and increased satisfaction in AHHC. This study aims to explore the patterns of engagement of escorts in Australian AHHC.MethodThis is a questionnaire-based, electronic survey of all 300 doctors involved in AHHC through the National Home Doctor Service (NHDS), Australia’s largest providers of the service. The survey explored the doctor’s experiences over the 12-month period from October 2013 to September 2014. ResultsThis survey received a total of 168 valid responses, giving a response rate of 56%. Nearly 61% of the doctors involved in AHHC engaged escorts (chauffeurs and chaperones). Of those doctors that engage chauffeurs, three-quarters do so “all or most times”, while only one-quarter engaged chaperones to the same degree of frequency. Hiring escorts is very popular among Brisbane (91.7%) and Sydney-based (88.2%) practitioners, but is unpopular in the City of Gold Coast (26.1%). There were moderate patronages in Adelaide (52.9%) and Melbourne Area (46.4%). Compared to males, females were less likely to drive themselves without escorts (OR 0.20; P < 0.01; CI [0.07–0.57]), but more likely to engage chauffeurs (OR 5.87; P = 0.03; CI [1.16–29.77]). Practitioners who were apprehensive were three times more likely to either engage escorts as chauffeurs (OR 3.10; P = 0.04; CI [1.05–9.15]) or as an accompanying chaperone if they self-drive (OR 3.03; P = 0.02; CI [1.16–7.89]).ConclusionMore needs to be done to increase the engagement of escorts by doctors involved in the Australian AHHC, particularly given their proven benefits in the service. Future studies may be needed to fully explore the real reasons behind the significant associations identified in this study.

Solutions Not Problems: A New Era in After-Hours Care?

The editorialists discuss the experience of after-hours care delivery in the Netherlands and why it should inspire other countries to invest in high-quality after-hours services.

Improving community access to terminal phase medicines through the implementation of a ‘Core Medicines List’ in South Australian community pharmacies

ObjectivesDifficulties accessing medicines in the terminal phase hamper the ability of patients to die at home. The aim of this study was to identify changes in community access to medicines...

Characteristics of patients presenting to an after-hours clinic: results of a MAGNET analysis.

After-hours access to general practice (GP) is critical to supporting accessibility and reducing emergency department demand. To understand who utilises after-hours GP services, this study examined the characteristics of presentations to an Eastern Melbourne after-hours clinic between 2005 and 2014. Descriptive analyses of patient and presentation characteristics, diagnoses, medications and pathology were conducted. Across the study period, 39.1% of presentations to the clinic (N=64,800) were by patients under 18 years of age. Females were found to attend more often than males, and nearly 79% of patients attended only once. The most common diagnoses were respiratory system diseases (13.4%), gastrointestinal system diseases (12.6%) and eye and ear problems (11.6%). Antibacterial medications accounted for over half (53.0%) of all prescriptions, with 34% of antibiotics prescribed to patients under 18 years of age. Seasonal variation in GP demand was also observed. Presenting patients differed from the wider GP patient population, with more young patients, and a higher proportion of prescriptions for antibacterial medications compared to other predominantly non-after-hours practices. Further research is required to understand the health-seeking, decision-making of patients who utilise after-hours GPs over predominantly non-after-hours primary care services, to inform service promotion and delivery strategies.

A Retrospective Review of the After-Hours Social Work Service in a Tertiary-Care Public Hospital in Australia

Purpose: After-hours social work (SW) services seem to be provided in many major healthcare centres but there appear to be no data describing these services, in terms of the number of patients seen, their characteristics, types of problems, SW interventions provided, their effectiveness or the impact of providing after-hours services on the provider. The aim of this study was to investigate the patient characteristics and types of interventions provided to patients who received an after-hours SW service and the effect of providing these services on the service-provider. Method: A retrospective review of data collected on patients who had received after-hours SW service for urgent/crisis scenarios over a three-year period in a tertiary-care public hospital in Australia was undertaken, with two illustrative case scenarios. Results: A total of 172 occasions of service were delivered, with most services provided to patients/families in the Emergency Department (ED) or Intensive Care Unit (ICU) following trauma or with a medical condition. Counselling for trauma, grief or loss were the types of interventions most often provided. Interventions were most frequently rated by the SW-provider as highly complex and imperative. At times, providing the after-hours service negatively impacted on the service-provider the following day, with tiredness and hypervigilance most frequently reported. Conclusion: An after-hours SW service within a tertiary-care hospital was provided approximately five times/month, predominantly involving counselling to patients/families in the ED or ICU, and rated as highly complex and imperative. These results provide evidence, albeit anecdotal, that an after-hours SW service is of value in this setting.

Urban-Rural Disparity in Geographical and Temporal Availability of Pediatric Clinics: A Nationwide Survey in Taiwan

The shortage and maldistribution of pediatricians affected after-hours pediatric services, especially in rural areas. Our study aimed to examine the urban-rural disparity in geographical and temporal availability of the pediatrician workforce in Taiwan by analyzing opening time schedules of all pediatric clinics throughout the country. The opening time schedules of nonhospital pediatric clinics were downloaded from the website of the National Health Insurance Administration in Taiwan for analysis. The geographical and temporal availability of pediatric clinics was calculated and stratified by urbanization level and opening time, which was divided into daytime and evening sessions over 1week. Each of 368 towns in Taiwan was also regarded as a unit of measurement to estimate the local availability of at least one pediatric clinic open in after-hours sessions. Among 1483 nonhospital pediatric clinics in Taiwan, the overwhelming majority were situated in urban (65.8%) and suburban (30.6%) areas. On average, a pediatric clinic provided 16.3 (standard deviation=3.04) sessions of services per week. One-third (34.7%, n=50) of 144 suburban towns and over three-fourths (77.4%, n=120) of 155 rural towns had no pediatric clinic. Most pediatric clinics remained open on weekday evenings (91.1%) and during Saturday daytime (91.8%). The percentage of open clinics gradually decreased over the weekend: Saturday evening (58.1%), Sunday daytime (33.4%), and Sunday evening (19.4%). Rural pediatric clinics remained closed mostly on weekends. On Sunday evenings, pediatric clinics were open only in 5.2% of rural towns, with a decline of 77.1%, whereas they were open in 78.3% of urban towns, with a decline of 18.2%. Pediatric clinics in Taiwan were unevenly distributed between urban and rural areas. The disparity of pediatric services became more obvious at weekends. The consequences of undersupplied rural pediatric care deserve further investigation.

Interprofessional collaboration between general physicians and emergency department services in Belgium: a qualitative study

Introduction: The use of emergency department (ED) services has known a significant rise in the past decade. Organizational factors, such as the models of after-hours primary medical care services, and the shortage of general practitioners (GPs) could explain this phenomena. But also demographic and societal elements combined with the problem of patient’s ‘inappropriate visits to the ED. In order to ensure continuity of care for patients, collaboration between GPs and EDs becomes increasingly essential. Not to mention the benefit of this collaboration for the healthcare system in terms of efficacy and efficiency.This papers explores positive experiences of collaboration between GPs and ED teams in Brussels and the French speaking regions of Belgium, with the objectives of 1) identifying the main concepts related to IC that are highly valued by actors; and 2) analyzing forces and opportunities of the Belgian context in terms of IC. Focusing on positive experiences is inspired from the Appreciative Inquiry (AI) philosophy which is based on the assumption that every organization has something that works well and these strengths can be the starting point to create a positive change.Methods: A series of eight focus groups (FG) with GPs and ED teams was conducted in Brussels and different French speaking regions between September 2014 and December 2015. FG lasted one and a half hours on average. Participants’ number varied between 6 and 12 per FG. They were audio recorded and transcribed verbatim. An interview guide was designed based on the first two phases of AI, “discovery and dream”. Transcripts were analyzed thematically using an inductive content analysis technique.Results: Findings showed that a positive experience of collaboration is mainly related to a high level of communication. Both GPs and EDs attach great importance to clear, timely, and accurate written reports, but also to oral communication. Phone calls are highly valued as they allow actors to interact directly, and negotiate the patient plan of care. Mutual acquaintanceship is another component of IC. Actors agree that knowing each other and being able to put a face to a name optimizes contact, enhances relationships and strengthens trust. Trust is also the result of previous experiences. It is manifested by seeking advice from each other and making joint decisions. Another finding is about power. A positive experience of power is mainly characterized by a relationship of equality without any dominance behavior. It shows in respectful and professional attitudes towards each other. Role clarification is also of particular importance. Knowing one’s own role and that of others and fulfilling that role is considered as a valuable lever for collaboration. It supposes that actors are aware of each other training, thus more confident in the competencies of the others. It also improves the referral process. The patient himself plays a major role in enhancing IC and can be the driving force in communication between actors. As for the political environment and the healthcare system in general, they don’t seem to play a significant role in promoting collaboration between GPs and EDs. With the absence of integration policies, data and information exchange system remains poorly developed; there are no incentive measures to encourage collaboration; no gatekeeping process; the out of hours GPs services are problematic for both parties; and the fee-per-service payment and the legislation on both parties financing encourage competition. Finally, actors’ priorities, in order to achieve better collaboration, include better communication and mutual acquaintanceship.Discussion: Opportunities for enhancing IC in the Belgian context include a recent report from the Belgian healthcare knowledge center addressing the organization and payment of ED services in Belgium and highlighting the necessity of increased collaboration between EDs and GPs. Although controversial, the report is definitely a starting point of negotiation toward better IC. Also the recent federal plan aiming at developing integrated and patient centered care for chronic patients by developing pilot projects which experiment and evaluate models of integration. As for the forces, they lie in the fact that mutual acquaintanceship happens informally, despite the lack of organized activities, and that actors are aware of the benefits of IC and ready to engage in a better relationship.Conclusion: In terms of cost-efficiency, the performance of the Belgian healthcare system remains poor. Several initiatives aiming at coordinating care between hospitals and primary care have been established. But until today, only rare strategies target the ED specifically. In the future, strategies to enhance collaboration should be seriously investigated if we aspire to integrating efficiently the different healthcare providers.

Help is just a phone call away: after-hours support for palliative care patients wishing to die at home.

The 24-hour support for palliative patients is the gold standard of health care in Australia. However, in the state of Tasmania after-hours telephone support was spatially fragmented and inequitable. In 2014, hospice@HOME, a pilot programme introduced in Tasmania in that year, implemented a state-wide after-hours palliative care support service--1800HOSPICE--offering 24-hour support, 7 days a week for palliative patients, caregivers and the public. Six months of after-hours call logs in combination with additional patient data, were analysed to evaluate the use and wider implications of a state-wide after-hours palliative care support number. Family and caregivers mainly used the after-hours support to request changes to support services (25.1%), report changes in patients' overall condition (23.6%) and request acute medical assistance (16.2%). Through the use of the after-hours services by all individuals involved in the care, end-of-life patients were able to reduce ambulance contact and emergency department admission, and thereby increase their likelihood of dying at home (for patients whose preference was to die at home). Overall, 24-hour palliative care telephone support was found to be a valuable tool for all individuals involved in the care of end-of-life patients.

In the Aftermath: Attitudes of Anesthesiologists to Supportive Strategies After an Unexpected Intraoperative Patient Death.

Although most anesthesiologists will have 1 catastrophic perioperative event or more during their careers, there has been little research on their attitudes to assistive strategies after the event. There are wide-ranging emotional consequences for anesthesiologists involved in an unexpected intraoperative patient death, particularly if the anesthesiologist made an error. We used a between-groups survey study design to ask whether there are different attitudes to assistive strategies when a hypothetical patient death is caused by a drug error versus not caused by an error. First, we explored attitudes to generalized supportive strategies. Second, we examined our hypothesis that the presence of an error causing the hypothetical patient death would increase the perceived social stigma and self-stigma of help-seeking. Finally, we examined the strategies to assist help-seeking. An anonymous, mailed, self-administered survey was conducted with 1600 consultant anesthesiologists in Australia on the mailing list of the Australian and New Zealand College of Anaesthetists. The participants were randomized into "error" versus "no-error" groups for the hypothetical scenario of patient death due to anaphylaxis. Nonparametric, descriptive, parametric, and inferential tests were used for data analysis. P' is used where P values were corrected for multiple comparisons. There was a usable response rate of 48.9%. When an error had caused the hypothetical patient death, participants were more likely to agree with 4 of the 5 statements about support, including need for time off (P' = 0.003), counseling (P' < 0.001), a formal strategy for assistance (P' < 0.001), and the anesthesiologist not performing further cases that day (P' = 0.047). There were no differences between groups in perceived self-stigma (P = 0.98) or social stigma (P = 0.15) of seeking counseling, whether or not an error had caused the hypothetical patient death. Finally, when an error had caused the patient death, participants were more likely to agree with 2 of the 5 statements about help-seeking, including the need for a formal, hospital-based process that provides information on where to obtain professional counseling (P' = 0.006) and the availability of after-hours counseling services (P' = 0.035). Our participants were more likely to agree with assistive strategies such as not performing further work that day, time off, counseling, formal support strategies, and availability of after-hours counseling services, when the hypothetical patient death from anaphylaxis was due to an error. The perceived stigma toward attending counseling was not affected by the presence or absence of an error as the cause of the patient death, disproving our hypothesis.