GP Cooperative Research Articles

Management of sepsis in out-of-hours primary care: a retrospective study of patients admitted to the intensive care unit

BackgroundSepsis is a life-threatening condition requiring urgent hospital treatment. The rates of recognition and doctors delay in primary care are currently unknown.AimTo explore the role of GP cooperatives in the pre-hospital care for sepsis patients.MethodA retrospective patient record study was conducted of sepsis patients admitted to an intensive care unit (ICU) in Ede, the Netherlands. Adult ICU patients admitted for community-onset sepsis between 2011 and 2015 were identified. Subsequently, all contacts with the co-located GP cooperative in the 72 hours before hospital admission were retrieved. Differences in mortality rates between subgroups were analysed using logistic regression analysis.ResultsOf 263 patients admitted to the ICU, 127 (48.3%) had prior GP cooperative contacts. These contacts concerned home visits (59.1%), clinic consultations (18.1%), direct ambulance deployment (12.6%) or telephone advice (10.2%). Patients assessed by a GP were referred in 64% after the first contact. The median delay to hospital arrival was 1.8 hours. In 43%, the GP had not suspected an infection. In this group the in-hospital mortality rate was significantly higher compared with patients with suspected infections (41.9% versus 17.6%). Mortality difference remained significant after correction for confounders.ConclusionGP cooperatives play an important role in pre-hospital management of sepsis and recognition of sepsis in this setting proved difficult. Efforts to improve management of sepsis in out-of-hours primary care should not be limited to patients with a suspected infection, but also include severely ill patients without clear signs of infection.

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care.

Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service. The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service. We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient's own GP, using a questionnaire. Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients' own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain. Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain.

Writing information transfers for out-of-hours palliative care: a controlled trial among GPs

Objective: The aim was to evaluate the effect of the implementation of an information handover form regarding patients receiving palliative care. Outcome was the information available for the out-of-hours GP co-operative. Design: We conducted a controlled trial. Setting: All GPs in Amsterdam, The Netherlands. Intervention: The experimental group (N = 240) received an information handover form and an invitation for a one-hour training, the control group (N = 186) did not receive a handover form or training. We studied contacts with the GP co-operative concerning patients in palliative care for the presence and quality of information transferred by the patient's own GP. Main outcome measures: Proportion of contacts in which information was available and proportion of adequate information transfer. Results. Overall information was transferred by the GPs in 179 of the 772 first palliative contacts (23.2%). The number of contacts in the experimental group in which information was available increased significantly after intervention from 21% to 30%, compared to a decrease from 23% to 19% in the control group. The training had no additional effect. The content of the transferred information was adequate in 61.5%. There was no significant difference in the quality of the content between the groups. Conclusion: The introduction of a handover form resulted in a moderate increase of information transfers to the GP co-operative. However, the total percentage of contacts in which this information was present remained rather low. GP co-operatives should develop additional policies to improve information transfer.Key Points The out-of-hours period is potentially problematic for the delivery of optimal palliative care, often due to inadequate information transfer. Introduction of a handover form resulted in a moderate increase of transferred information. The percentage of palliative contacts remained low in cases where information was available. Adequate information was transferred in more than half of the cases.

Association between general practice characteristics and use of out-of-hours GP cooperatives.

BackgroundThe use of out-of-hours healthcare services for non-urgent health problems is believed to be related to the organisation of daytime primary care but insight into underlying mechanisms is limited. Our objective was to examine the association between daytime general practice characteristics and the use of out-of-hours care GP cooperatives.MethodsA cross-sectional observational study in 100 general practices in the Netherlands, connected to five GP cooperatives. In each GP cooperative, we took a purposeful sample of the 10 general practices with the highest use of out-of-hours care and the 10 practices with the lowest use.Practice and population characteristics were obtained by questionnaires, interviews, data extraction from patient registration systems and telephone accessibility measurements. To examine which aspects of practice organisation were associated with patients’ use of out-of-hours care, we performed logistic regression analyses (low versus high out-of-hours care use), correcting for population characteristics.ResultsThe mean out-of-hours care use in the high use group of general practices was 1.8 times higher than in the low use group. Day time primary care practices with more young children and foreigners in their patient populations and with a shorter distance to the GP cooperative had higher out-of-hours primary care use. In addition, longer telephone waiting times and lower personal availability for palliative patients in daily practice were associated with higher use of out-of-hours care. Moreover, out-of-hours care use was higher when practices performed more diagnostic tests and therapeutic procedures and had more assistant employment hours per 1000 patients.Several other aspects of practice management showed some non-significant trends: high utilising general practices tended to have longer waiting times for non-urgent appointments, lower availability of a telephone consulting hour, lower availability for consultations after 5 p.m., and less frequent holiday openings.ConclusionsBesides patient population characteristics, organisational characteristics of general practices are associated with lower use of out-of-hours care. Improving accessibility and availability of day time primary day care might be a potential effective way to improve the efficient use of out-of-hours care services.

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison

BackgroundEmergency Departments (ED) in Switzerland are faced with increasing numbers of patients seeking non-urgent treatment. The high rate of walks-ins with conditions that may be treated in primary care has led to suggestions that those patients would best cared for in a community setting rather than in a hospital. Efficient reorganisation of emergency care tailored to patients needs requires information on the patient populations using the various emergency services currently available. The aim of this study is to evaluate the differences between the characteristics of walk-in patients seeking treatment at an ED and those of patients who use traditional out-of-hours GP (General Practitioner) services provided by a GP-Cooperative (GP-C).MethodsIn 2007 and 2009 data was collected covering all consecutive patient-doctor encounters at the ED of a hospital and all those occurring as a result of contacting a GP-C over two evaluation periods of one month each. Comparison was made between a GP-C and the ED of the Waid City Hospital in Zurich. Patient characteristics, time and source of referral, diagnostic interventions and mode of discharge were evaluated. Medical problems were classified according to the International Classification of Primary Care (ICPC-2). Patient characteristics were compared using non-parametric tests and multiple logistic regression analysis was applied to investigate independent determinants for contacting a GP-C or an ED.ResultsOverall a total of 2974 patient encounters were recorded. 1901 encounters were walk-ins and underwent further analysis (ED 1133, GP-C 768). Patients consulting the GP-C were significantly older (58.9 vs. 43.8 years), more often female (63.5 vs. 46.9%) and presented with non-injury related medical problems (93 vs. 55.6%) in comparison with patients at the ED. Independent determining factors for ED consultation were injury, male gender and younger age. Walk-in distribution in both settings was equal over a period of 24 hours and most common during daytime hours (65%).Outpatient care was predominant in both settings but significantly more so at the GP-C (79.9 vs. 85.7%).ConclusionsWe observed substantial differences between the two emergency settings in a non gate-keeping health care system. Knowledge of the distribution of diagnoses, their therapy, of diagnostic measures and of the factors which determine the patients' choice of the ED or the GP-C is essential for the efficient allocation of resources and the reduction of costs.

Out-of-hours palliative care provided by GP co-operatives: availability, content and effect of transferred information

BackgroundOut-of-hours GP care in England, Denmark and the Netherlands has been reorganised and is now provided by large scale GP co-operatives. Adequate transfer of information is necessary in order to assure continuity of care, which is of major importance in palliative care. We conducted a study to assess the availability, content and effect of information transferred to the GP co-operatives.MethodsCross-sectional exploratory study of all palliative care phone calls during a period of one year to a GP co-operative.ResultsThe total number of phone calls about patients who needed palliative care was 0.75% of all calls to the GP co-operative. Information was transferred by GPs on 25.5% of palliative care patient calls, and on 12% of palliative care patient calls from residential care homes. For terminally ill patients the number of information transfers increased to 28.9%. When information was transferred, the content consisted mainly of clinical data. Information about the diagnosis and current problems was transferred in more than 90% of cases, information about the patient's wishes in 45% and information about the patient's psychosocial situation in 30.5% of cases.A home visit was made after 53% of the palliative care calls.When information was transferred, fewer patients were referred to a hospital.ConclusionGPs frequently fail to transfer information about their palliative care patients to the GP co-operatives. Locums working at the GP co-operative are thus required to provide palliative care in complex situations without receiving adequate informationGPs should be encouraged and trained to make this information available to the GP co-operatives.

Rude or aggressive patient behaviour during out-of-hours GP care: Challenges in communication with patients

GPs in out-of-hours care report that they feel at risk of rude or aggressive patient behaviour. We tried to get information about the incidence, types and patient characteristics of rude or aggressive behaviour. Retrospective, observational study involving the analysis of medical records of all patients who contacted a Dutch GP cooperative between June 2001 and June 2002. Of the 36.259 patient records, 545 (1.5%) reported rude behaviour, 67 (0.2%) reported verbal aggression and physical aggression was not reported. Anxiety, sorrow, or pain was reported by patients in 49.7% of the cases with rude or aggressive behaviour. The conflict topic between patients and professional was mostly the request of a home visit (21.8%), or a centre consultation (17.3%). Patients with mental health problems (OR 2.3 CI 1.8-3.1) were more at risk for rude or aggressive behaviour. Rude and aggressive behaviour on GP cooperatives occurs relative seldom and is associated with anxiety, sorrow, and pain. The wish to see a doctor instead getting a telephone advice is a frequent conflict topic between patient and professional. The findings suggest that improved communication at the telephone, particularly exploring the expectation, needs and worries of patients, may reduce aggressive behaviour.

General practice cooperatives: long waiting times for home visits due to long distances?

BackgroundThe introduction of large-scale out-of-hours GP cooperatives has led to questions about increased distances between the GP cooperatives and the homes of patients and the increasing waiting times for home visits in urgent cases. We studied the relationship between the patient's waiting time for a home visit and the distance to the GP cooperative. Further, we investigated if other factors (traffic intensity, home visit intensity, time of day, and degree of urgency) influenced waiting times.MethodsCross-sectional study at four GP cooperatives. We used variance analysis to calculate waiting times for various categories of traffic intensity, home visit intensity, time of day, and degree of urgency. We used multiple logistic regression analysis to calculate to what degree these factors affected the ability to meet targets in urgent cases.ResultsThe average waiting time for 5827 consultations was 30.5 min. Traffic intensity, home visit intensity, time of day and urgency of the complaint all seemed to affect waiting times significantly. A total of 88.7% of all patients were seen within 1 hour. In the case of life-threatening complaints (U1), 68.8% of the patients were seen within 15 min, and 95.6% of those with acute complaints (U2) were seen within 1 hour. For patients with life-threatening complaints (U1) the percentage of visits that met the time target of 15 minuts decreased from 86.5% (less than 2.5 km) to 16.7% (equals or more than 20 km).Discussion and conclusionAlthough home visits waiting times increase with increasing distance from the GP cooperative, it appears that traffic intensity, home visit intensity, and urgency also influence waiting times. For patients with life-threatening complaints waiting times increase sharply with the distance.

Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: Determinants of a negative evaluation

Objective The shift towards large-scale organization of out-of-hours primary healthcare in different western countries has created an important role for the nurse telephone consultation. We explored the association between negative patient evaluation of nurse telephone consultations and characteristics of patients and GP cooperatives. Methods A cross-sectional study using postal patient questionnaires sent to patients receiving a nurse telephone consultation from one of 26 GP cooperatives in the Netherlands. Results The total response was 49.3% (2583/5239). Negative evaluations were most frequently encountered for the general information received on the GP cooperative (35%). When patients expected a centre consultation or home visit, but only received a nurse telephone consultation, they were more negative about the accessibility (OR 1.7, CI 1.4–2.1) and nurse telephone consultation (OR 4.2, CI 3.2–5.6). In the presence of a special supervising telephone doctor at the cooperative's call centre, nurse telephone consultation was evaluated significantly less negative (OR 0.4, CI 0.2–0.8). Conclusion Expectation of care mode was most strongly associated with a negative evaluation of nurse telephone consultation. The presence of a supervising telephone doctor may lead to a better evaluation of nurse telephone consultations. Practice implications More attention should be paid to the provision of patient information on the GP cooperative and discrepancies between the care expected and the care offered.

Patient satisfaction with large-scale out-of-hours primary health care in The Netherlands: development of a postal questionnaire

Since the turn of the millennium, out-of-hours primary health care in The Netherlands has faced a substantial change from small locum groups towards large GP cooperatives. Improving the quality of care requires evaluation of patient satisfaction. To develop a reliable postal questionnaire for wide-scale use by patients contacting their out-of-hours GP cooperative and to present the results of a national survey. Literature review and interviews with both patients and health carers were carried out to identify issues of potential relevance, followed by two postal pilot studies and additional interviews to remove or rephrase items. Finally, postal questionnaires were sent to 14,400 people who contacted one of 24 GP cooperatives in The Netherlands. Overall response was 52.2% for all types of contact. Three scales were identified prior to the field phase and confirmed by principal components analysis: telephone nurse, doctor and organization. Reliability was high, with Cronbach's alphas and intraclass correlation coefficients exceeding 0.70 for all scales. Only items in the organization scale showed clear differences among the participating cooperatives. Respondents receiving telephone advice showed lower levels of satisfaction than respondents with other types of contact (P < 0.001); centre consultation scored lower than home visit (P < 0.030 or less for all differences). A reliable measure of patient satisfaction has been developed that can also be used for the comparison of GP cooperatives on an organizational level. Overall satisfaction was high, showing highest levels for home visit and lowest levels for telephone advice.

The impact of standalone call centres and GP cooperatives on access to after hours GP care: a before and after study adjusted for secular trend

The After Hours Primary Medical Trials were initiated by the Australian government to redress difficulties in after hours (AH) GP care in areas of high need. The study's objective is to study the impact of two standalone call centres and one GP cooperative offering comprehensive services, in improving consumer access to services for residents of a defined geographic area. A pre-post design was used to evaluate their impact after adjusting for secular trend at a national level. Access was considered in terms of availability, accessibility, affordability, acceptability and responsiveness of care. Unmet need and ease of obtaining AH telephone professional medical advice were also considered. Pre-trial and post-trial telephone surveys of two separate random samples of approximately 350 households using AH services in each trial area as well as in a national sample outside the trial areas. Consumer acceptability and affordability increased in residents in the area served by the GP cooperative. Access, however measured, did not improve in either of the standalone call centre areas. Reduction in unmet need approached but did not achieve statistical significance in most but not all trial areas. Improvements in access in the GP cooperative conformed to expectations based on current and pre-existing AH care arrangements put in place. Absence of improvements in access in the standalone call centres did not conform to expectations but may be partly explained by the reductions in consumer acceptability, following introduction of telephone triage systems reported elsewhere.

The wisdom lost in knowledge: changes in the face of general practice

The wisdom lost in knowledge: changes in the face of general practice

Patients' experiences of receiving telephone advice from a GP co-operative.

The use of the telephone to deliver health care advice has increased considerably in recent years. Little research has been carried out to explore the experience of patients who receive such advice and its acceptability. The aim of this study is to describe the expectations of patients, or third party callers, who had contacted a GP out-of-hours co-operative and their satisfaction with telephone advice received. Semi-structured interviews were conducted by telephone 7-10 days after contact with one inner city GP co-operative. A total of 47 telephone consultations were followed up with an interview. Of these, 23 (48.9%) callers had expected to be offered a home visit when they called. Reasons for wanting a home visit were either to do with the nature of the condition and its perceived severity, problems in being able to attend the primary care centre and the risks of travel, or because of problems in communicating over the telephone. Satisfaction with telephone consultations centred mostly on the doctor being able to provide reassurance and give adequate time to allay concerns. The most common reasons given for dissatisfaction were the caller feeling that the doctor could not make a correct diagnosis without having seen the patient, or the caller being made to feel that they were wasting the doctor's time. Many patients were anxious about their ability to describe symptoms over the telephone, or understand and follow the advice that they received. There appears to be a need for patients to be better informed about the service they can expect to receive from GP co-operatives. Recent developments such as NHS Direct may have an influence on the telephone consultation rate to GP co-operatives.

Patient-perceived benefits of and barriers to using out-of-hours primary care centres.

The rapid growth of GP co-operatives has encouraged the development of primary care centres, but little is known about patients' views and experiences of these new forms of out-of-hours service delivery. This study was designed to understand patients' views, expectations and experiences of attending an out-of-hours primary care centre which was part of an inner London GP co-operative. Systematic samples of patients using the out-of-hours service received semi-structured interviews covering the decision to contact the service, expectations and experience of the service and, if relevant, the experience of travelling to the primary care centre. Interviews were conducted by telephone between 7 and 10 days after patient contact. Interviews were completed with 55.4% (72/130) of sampled patients who were primary care centre attenders, 50.0% (47/94) of those receiving telephone advice and 45.3% (53/117) of those receiving a home visit. Most attenders of the primary care centre said that they were satisfied with the consultation (90.0%, 65) and were able to get all the help they needed (83%, 60). The speed of being seen and the opportunity of having a face-to-face consultation were key benefits identified. For some, this outweighed difficulties experienced in attending the centre, including arranging transport, caring for other children, managing several children on the journey and travelling while ill. The main barriers patients identified for not wanting to attend the primary care centre included feeling too ill to travel, having other dependants to care for or lacking transportation. While primary care centres offer patients speedy access to face-to-face consultations, there are a range of obstacles which are encountered. Those who are socially disadvantaged appear likely to experience greatest difficulty, raising concerns about equity in access to services. Out-of-hours services may need to give consideration to patient transport and a more flexible approach to visiting at home if such inequities are to be avoided.