Physician-led Care Research Articles

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care \u2013 a cost-effectiveness analysis of a pragmatic trial

BackgroundOver the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial.MethodsPatients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve.Results69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72–80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care.ConclusionThese findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients’ perception of this model of care are needed.Clinical trial registrationThe study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

New models of care integrating more autonomous roles for physiotherapists: a narrative review

With the increased prevalence of non-communicable diseases and chronic disorders, including musculoskeletal disorders, access to care is limited in many health care systems and new multidisciplinary collaborative models of care have now been implemented in several countries in an effort to improve access to care. The paper aimed to describe the characteristics and present relevant evidence supporting different models of care that integrate physiotherapists as primary or secondary care practitioners for the management of patients with non-communicable diseases or chronic disorders. On the basis of a literature review up to August 2020 in 4 major bibliographical databases, we searched for studies of any design, including systematic reviews with or without meta-analysis and position statements, that were related to direct access physiotherapy and advanced practice physiotherapy models of care. The impact of direct access physiotherapy and advanced practice physiotherapy models of care is presented in terms of clinical outcomes, patient satisfaction, health care resource use and costs. These models appear to provide equal or better outcomes in terms of access to care, quality of care, and patients’ satisfaction. The strength of the evidence is variable, and outcomes vary depending on clinical settings, roles of physiotherapists, and characteristics of patients. This review highlights that these enhanced roles for physiotherapists, such as diagnosing, ordering diagnostic tests, or referring patients to physicians, in both primary and secondary care settings, are beneficial and may help optimize patients’ journey by providing earlier access to effective and efficient services compared with physician-led usual care models.

The effectiveness of the role of advanced nurse practitioners compared to physician-led or usual care: A systematic review.

To evaluate the effectiveness of the role of advanced nurse practitioners compared to physicians-led/ usual care (care managed by medical doctors or non-advanced nurse practitioners). Advanced nurse practitioners contribute to the improvement of quality patient care and have substantial potential to optimise the health of people globally. Since the formal recognition of advanced nurse practitioners by the International Council of Nurses, among others, the role has been adopted across most departments and clinical specialties, particularly in high-income countries. Systematic review of primary research evidence. MEDLINE, EMBASE, CINAHL, Cochrane registry, Cochrane trials, and Cochrane EPOC (PDQ Evidence) were searched for randomised controlled trials (RCTs) of patient care and health resource utilisation outcomes associated with advanced nurse practitioners. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The chosen articles were restricted to full-text English language trials published in the last 20 years, incorporating comparators of usual care. Search terms were limited to variations of advanced nurse practitioner role and practice. The eligible studies were bias risk assessed and quality assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Clinical and service outcomes were analysed using narrative synthesis as the marked heterogeneity between studies precluded meta-analysis. Thirteen RCTs were reviewed. All of them were conducted across high-income countries within primary care and hospital settings involving paediatric and adult patients. Five trials were assessed as high quality, and eight were of low to moderate quality. Positive effects were demonstrated for the impact of advanced nurse practitioners on usual care; for indigestion, mean difference [MD] 2.3: 95% CI 1.4, 3.1]), perceptions of health status [ (MD -140.6; 95% CI -184.8, -96.5)], satisfaction levels [ (MD ranged from -8.79; 95% CI -13.59, -3.98 to 0.61; 95% CI -4.84, 6.05)], physical function (1.58 [SD 0.76] v. 1.81 [SD 0.90]), and blood pressure control (systolic [133 [SD 21] v. 135 [SD 19] mmHg p=0.04] and diastolic [77 [SD 10] v. 80 [SD 11] mmHg p=0.007]) were looked at. Positive effects related to service provision included improved patient satisfaction and reductions in waiting times and costs, which significantly favored advanced nurse practitioners (all p<0.05). The evidence of this review supports the positive impact of advanced nurse practitioners on clinical and service-related outcomes: patient satisfaction, waiting times, control of chronic disease, and cost-effectiveness especially when directly compared to medical practitioner-led care and usual care practices - in primary, secondary and specialist care settings involving both adult and pediatric populations.

Comparison of vaginal birth outcomes in midwifery-led versus physician-led setting: A propensity score-matched analysis.

BackgroundExperts in many countries are recommending a scaling up midwifery-led care as a model to improve maternal and newborn outcomes, reduce rates of unnecessary interventions, realise cost savings, and facilitate normal spontaneous vaginal birth.ObjectiveThe aim of this study was to compare midwifery-led and obstetrician-gynaecologist-led care-related vaginal birth outcomes.ParticipantsPregnant women in Kaunas city maternity care facilities.MethodsA propensity score-matched case–control study of midwifery-led versus physician-led low-risk birth outcomes. Patient characteristics and outcomes were compared between the groups. Continuous variables are presented as mean ± standard deviation and analysed using the Mann–Whitney U test. Categorical and binary variables are presented as frequency (percentage), and differences were analysed using the chi-square test. Analyses were conducted separately for the unmatched (before propensity score matched [PSM]) and matched (after PSM) groups.ResultsAfter adjusting groups for propensity score, postpartum haemorrhage differences between physician-led and midwifery-led labours were significantly different (169.5 and 152.6 mL; p = 0.026), same for hospital stay duration (3.3 and 3.1 days, p = 0.042). Also, in matched population, significant differences were seen for episiotomy rates (chi2 = 4.8; p = 0.029), newborn Apgar 5 min score (9.58 and 9.76; p = 0.002), and pain relief (chi2 = 14.9; p = 0.002). Significant differences were seen in unmatched but not confirmed in matched population for obstetrical procedures used during labour, breastfeeding, birth induction, newborn Apgar 1 min scores, and successful vaginal birth as an overall spontaneous vaginal birth success measure.ConclusionThe midwifery-led care model showed significant differences from the physician-led care model in episiotomy rates, hospital stay duration and postpartum haemorrhage, and newborn Apgar 5 min scores. Midwifery-led care is as safe as physician-led care and does not influence the rate of successful spontaneous vaginal births.

Effect of COVID-19 on smoking cessation outcomes in a large primary care treatment programme: an observational study

ObjectivesThe COVID-19 pandemic has changed patterns of smoking, other substance use and other health-related behaviours, leading to a virtualisation of non-urgent medical care. In this study, we examine associated changes...

Overall mortality in older people receiving physician-led home visits: a multicentre prospective study in Japan.

BackgroundJapan has the most rapidly ageing population in the world. The Japanese government has, therefore, promoted physician-led home health care for frail and disabled people.ObjectivesTo describe mortality among older people receiving physician-led health care at home or at a nursing home in Japan and to identify risk factors.MethodsThis was a multicentre prospective cohort study. Participants were aged ≥65 years and had started to receive regular physician-led health care at home or at nursing homes from 13 facilities between 1 February 2013 and 31 January 2016. The observation period ended on 31 January 2017. We used a biopsychosocial approach for exploratory analysis of 13 variables to identify mortality risk factors.ResultsThe median (25th to 75th percentile) observation time was 417 (121–744) days. Of 825 participants, 380 died. The total cumulative survival for 180, 360, 720 and 1440 days was 73.4% (95% confidence interval: 70.2–76.3), 64.2% (60.8–67.5), 52.6% (48.8–56.3) and 34.6% (23.5–46.0). The Kaplan–Meier cumulative survival curve showed a steep drop during the first 6 months of observation. A multivariate Cox proportional hazard model showed that sex (male), high Charlson Comorbidity Index score, low serum albumin level, low Barthel Index score, receipt of oxygen therapy, high Cornell Scale for Depression in Dementia score and non-receipt of public assistance were associated with mortality.ConclusionsOverall mortality in physician-led home visits in Japan was described and mortality risk factors identified. Public assistance receipt was associated with lower mortality.

Cost Analysis of a Dedicated Outpatient Clinic in Patients With Newly Diagnosed Atrial Fibrillation.

The aim of this study was to assess healthcare utilization costs of a dedicated outpatient clinic for patients with atrial fibrillation (AF). We conducted a registry-based retrospective study in patients with a first-time AF diagnosis from 2009 to 2011 (control group) and 2013 to 2015 (intervention group). The control group had physician-led usual care, and the intervention group received multidisciplinary care. The primary outcome was total costs of AF-related resource utilization. Exploratory outcomes were ischemic stroke, intracranial hemorrhage, and all-cause mortality. Multiple regression methods were used to control for confounders in the assessment of effects on outcomes. A total of 1552 patients were included, hereof 850 in the intervention group. Total AF-related costs were €2746 for the control group and €3154 for the intervention group, which was not statistically significant. Average outpatient costs were significantly higher in the control group than in the intervention group (€522 vs €344, respectively; P = .003). There was no difference in the number of AF-related hospital admissions and outpatient visits between the control group and the intervention group (incidence risk ratio, 1.03 vs 0.85; and 95% confidence interval, 0.92-1.16 vs 0.69-1.05, respectively). There was a trend toward reduced all-cause mortality (hazard ratio, 0.86; 95% confidence interval, 0.63-1.16) in the intervention group, which was not statistically significant. Total expenses for AF-related hospital resource utilization in the intervention group were higher, but the expenses for AF-related outpatient visits were significantly lower. There was a trend toward lower all-cause mortality in the intervention group, although the differences were not statistically significant. More research is needed investigating whether a multidisciplinary AF clinic is cost-effective.

Implementation of advanced practice nursing for minor orthopedic injuries in the emergency care context: A non-inferiority study

AimsTo evaluate the implementation of advanced practice nursing for patients with minor orthopedic injuries, including comparison of outcomes in relation to advanced practice nurse versus standard (physician-led) care models. DesignA non-inferiority study was performed in an emergency department in Norway, where advanced practice nursing is in an initial stage of implementation. The non-inferiority design was chosen to test whether the new advanced practice nursing model does not compromise quality of care compared to the standard care model already in use. MethodsPatients with minor orthopedic injuries were assessed and treated by either advanced practice nursing or standard (physician-led) care models. Participating patients were assigned to the professional available at presentation. In the nursing model, registered nurses worked at an advanced level/applied advanced practice nursing following in-house-training. Senior orthopedic specialists evaluated the diagnostic and treatment accuracy in both models. Data were collected in a tool developed for this study, from May to October 2019. ResultsIn total, 335 cases were included, of which 167 (49.9%) were assessed and treated in the nursing model. Overall, correct diagnosis was found in 97.3% (n = 326) of the cases, and correct treatment was found in 91.3% (n = 306) of the cases. In comparison of missed diagnosis between advanced practice nurse and the standard (physician-led) care model showed inconclusive results (risk ratio: 0.29, 95% CI: 0.06–1.36). In comparison of treatment outcomes, the results showed that the advanced practice nursing model was non-inferior (risk ratio: 0.45, 95% CI: 0.21–0.97). ConclusionAdvanced practice nursing care models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. Further implementation of the advanced practice nurse care model is encouraged.

Corporate Partnerships Revisited: What's in It for You?

Article| March 2021 Corporate Partnerships Revisited: What's in It for You? Donald E. Arnold, MD, FASA Donald E. Arnold, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor March 2021, Vol. 85, 21. https://doi.org/10.1097/01.ASM.0000737064.12476.ad Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Donald E. Arnold; Corporate Partnerships Revisited: What's in It for You?. ASA Monitor 2021; 85:21 doi: https://doi.org/10.1097/01.ASM.0000737064.12476.ad Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: partnerships The past year has reminded us all how vital our members and our specialty are. Thanks to support from so many, even in this difficult time, ASA has responded with broad, effective engagement during the public health emergency and with timely, specific support for members to improve patient care in communities where we practice. We have maintained committed focus on our core values – patient safety, physician-led care, and scientific discovery – while innovating in quality and safety. Through these commitments, we have continued to advance the practice of anesthesiology and have worked to secure better current and future care for our patients and better practice environments for our members. Some of the continuing support we value stems from corporate partners, a group that can be taken for granted, but who are also essential in furthering our good work.... © 2021 American Society of Anesthesiologists (ASA), All Rights Reserved.2021 You do not currently have access to this content.

Development and implementation of a cardiac resynchronisation therapy care pathway: improved process and reduced resource use

BackgroundCardiac resynchronisation therapy (CRT) requires intensive, complex and multidisciplinary care to maximize the clinical benefit. In current practice this is typically a task for highly specialised physicians. We report on...

The prevalence and the most significant sources of occupational burnout syndrome amongst anesthetic technicians in Saudi Arabia: A cross-sectional survey.

Aims:To detect the prevalence and the most significant sources of occupational burnout syndrome among anesthetic technicians in Saudi Arabia and draw recommendations that can reduce the level of this syndrome.Settings and Design:A cross-sectional descriptive survey was conducted in a central hospital in Saudi Arabia.Methods:Maslach Burnout Inventory and a self-created questionnaire was utilized to survey seventeen anesthesia technicians in order to capture the prevalence and most significant sources of burnout.Statistical Analysis Used:Descriptive statistics were utilized to conduct the statistical analysis.Results:Occupational burnout syndrome has been found in 29%. A level of emotional exhaustion was critically high in 41.2%. Likewise, a level of depersonalization was extremely high in 58.8%, while 76.5% of anesthetic technicians lacked personal accomplishments. There are several sources perceived by anesthetic technicians as the most significant sources of their occupational burnout syndrome. These sources include staff shortage, high workload, occupational hazards, and poor teamwork. However, the limited career pathway of anesthesia technicians seems to be the main predictor.Conclusions:A critically high prevalence of occupational burnout syndrome was found among anesthetic technicians, which is the highest among all studies reviewed worldwide. Several recommendations have been made which require urgent implementation into practice in order to protected practitioners' wellbeing and decrease their rate of turnover. These recommendations include implementing physician-led team-based care, provision of training and resources, fostering equity in a workplace and provision of hazard pay.

Commentary: What impact do specialist and advanced-level nurses have on people with heart failure compared to physician-led care? A literature review.

Commentary: What impact do specialist and advanced-level nurses have on people with heart failure compared to physician-led care? A literature review.

What impact do specialist and advanced-level nurses have on people living with heart failure compared to physician-led care? A literature review.

The inclusion of specialist nurses in multi-disciplinary teams is the current gold standard for care of people with heart failure (HF) in the UK; however, they remain underutilised in practice. Though existing systematic reviews favourably compare advanced nursing roles to physician-led care, none has focused solely on HF. To investigate the impact of specialist and advanced nurse-led care on the clinical outcomes, quality of life and satisfaction of people with HF compared to physician-led care. Literature review and narrative synthesis. This review included 12 studies and categorised their measured outcomes into five domains: mortality; hospital admissions and length of stay; HF diagnosis and management; quality of life and patient satisfaction; and finally, self-assessment and self-care. Five studies appraised as medium or low risk of bias suggest the impact of specialist and advanced-level nurses on people with HF to be broadly equivalent to physicians regarding mortality, hospital admissions and length of stay, while superior in terms of self-assessment and self-care behaviours. There were too few studies of sufficient methodological quality to draw definitive conclusions. However, no evidence was found to suggest that nurse-led services are any less effective or safe than physician-led services.

General medicine at the frontline of acute care delivery: Comparison with family medicine hospitalist model implementation in Singapore

Introduction This mixed methods study seeks to assess the clinical outcomes and qualitative insights associated with the pragmatic implementation of a general medicine (GM) physician-led inpatient care model, first at Alexandra Hospital (AH) and then at Sengkang General Hospital (SKH), and to compare them with findings reported in an earlier implementation of the family medicine (FM) hospitalist model in Singapore. Methods Anonymous quantitative demographic and clinical data including length of stay, 30-day readmission rate, inpatient mortality rate and gross cost of hospitalisation bills were extracted from the hospital information system. Comparative analyses with the FM hospitalist model and usual care were made. Secondary qualitative data that were gathered focused on increased understanding of the proposed model, its perceived challenges and future opportunities for its implementation. Results The adapted GM care model implemented first at AH and then at SKH seemed to suggest that such a model run by physicians from various backgrounds was capable of producing similarly superior outcomes when compared with the FM hospitalist model piloted in 2011, which was juxtaposed with usual care. With regard to qualitative insights, three findings were reported: (a) perception of and mindset in relation to generalists, which illustrates the barriers to implementing GM; (b) education and training of generalists, which underlines the current lack of adequate supply of GM specialists; and (c) operational issues of care model implementation, which highlights the current mismatches between the prevailing healthcare philosophy and the requirements for successful implementation of the GM care model. Conclusion The success of a GM care model hinges on how it is operationalised. With clear protocols, definitions, and a high level of protocol compliance by healthcare team members, the intended outcomes show promise for replication at other interested sites.

Comparing quality of care in medical specialties between nurse practitioners and physicians.

The American health care system is facing a growing health care provider shortage in primary and specialty care settings. Research has established that nurse practitioners (NPs) match or exceed their physician colleagues in providing quality care in primary care settings. This systematic review aimed to compare the quality of NP versus physician-led care in outpatient specialty care setting for clinical outcomes patient satisfaction. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the literature search (CINAHL, PubMed, and Cochrane Library) and interpretation of findings. Of the 228 articles that met the inclusion/exclusion criteria, 11 were selected for further review. Studies were conducted from 1995 to 2016 across four countries and spanned 10 distinct medical specialties. As a whole, these studies demonstrated that NPs in specialty settings perform as well as physicians terms of clinical safety and positive patient outcomes. Nurse practitioners matched or exceeded their physician counterparts in patient education and satisfaction. Nurse practitioners are a feasible option for addressing specialty care shortages. Further research should investigate whether NPs and physicians are equally prepared to provide equivalent care immediately following their respective postbaccalaureate programs. If not, studies should explore specific training duration and elements NPs require to provide equivalent care.

Effects of Wait Times on Treatment Adherence and Clinical Outcomes in Patients With Severe Sleep-Disordered Breathing

Sleep-disordered breathing (SDB) is common and associated with substantial adverse health consequences. Long wait times for SDB care are commonly reported; however, it is unclear whether wait times for care are associated with clinical outcomes. To evaluate the association of wait times for care with clinical outcomes for patients with severe SDB. This study is a secondary analysis of a randomized clinical noninferiority trial comparing management by alternative care practitioners (ACPs) with traditional sleep physician-led care between October 2014 and May 2017. The study took place at Foothills Medical Centre Sleep Centre, a tertiary care multidisciplinary sleep clinic at the University of Calgary. Patients with severe SDB (defined as a respiratory event index ≥30 events per hour during home sleep apnea testing, mean nocturnal oxygen saturation ≤85%, or suspected sleep hypoventilation syndrome) were recruited for the study. Patients were excluded if they were suspected of having a concomitant sleep disorder other than SDB or had previously been treated with positive airway pressure (PAP) therapy for SDB. Data were analyzed from October 2017 to January 2020. Outcomes were assessed 3 months after treatment initiation with adherence to PAP therapy as the primary outcome. Secondary outcomes included Epworth Sleepiness Scale score, health-related quality of life, and patient satisfaction measured using the Visit-Specific Satisfaction Instrument-9. Multiple regression models were used to assess the associations between wait times and each of the outcomes. t tests were used to compare wait times for patients who were adherent to PAP therapy (≥4 hours per night for 70% of nights) with those for nonadherent patients. One hundred fifty-six patients (112 [71.8%] men; mean [SD] age, 56 [12] years) were included in the analysis. The mean time from referral to initial visit was 88 days (95% CI, 79 to 96 days), and the mean time to treatment was 123 days (95% CI, 112 to 133 days). Shorter wait time to treatment initiation was associated with adherence to PAP therapy (odds ratio, 0.99; 95% CI, 0.98 to 0.99; P = .04), greater improvement in Epworth Sleepiness Scale score (mean coefficient, -9.37; 95% CI, -18.51 to -0.24; P = .04), and higher Visit-Specific Satisfaction Instrument-9 score (mean coefficient, -0.024; 95% CI, -0.047 to -0.0015; P = .04) at 3 months. Compared with nonadherent patients, those who were adherent to treatment waited a mean of 15 fewer days (95% CI, 12 to 19 days) for initial assessment (P = .07) and 30 fewer days (95% CI, 23 to 35 days) for treatment initiation (P = .008). Earlier initiation of treatment for severe SDB was associated with better PAP adherence and greater improvements in daytime sleepiness and patient satisfaction. These findings suggest that system interventions to improve timely access may modify patient behavior and improve clinical outcomes. ClinicalTrials.gov Identifier: NCT02191085.

Prehospital critical care is associated with increased survival in adult trauma patients in Scotland

BackgroundScotland has three prehospital critical care teams (PHCCTs) providing enhanced care support to a usually paramedic-delivered ambulance service. The effect of the PHCCTs on patient survival following trauma in Scotland...

Implementation of advanced practice nursing for orthopaedic patients in the emergency care context - A study protocol for outcome studies.

To evaluate the implementation of advanced practice nursing in emergency care in Norway for patients with orthopaedic injuries, including hip fractures. The outcomes relate to quality of care and patient trust. A non-inferiority study comparing an advanced practice nursing care model with a standard (physician-led) care model. Data will be collected from patient records and through the Patient Trust Questionnaire, completed by patients. The data will be analysed by descriptive and inferential statistics. Funding for the research was granted in 2015 and the regional ethical committee approved the current study in February 2019. In Norway and the other Nordic countries, advanced practice nursing is still in its infancy, especially in the emergency care context. This study will evaluate advanced practice nursing in this new context. The study will add to knowledge on the quality of care provided for orthopaedic patients with minor orthopaedic injuries or hip fractures as delivered by advanced practice nurses and physicians, respectively. It will also evaluate how well-advanced practice nursing is accepted by patients in this new context.

Nurse-led care versus physician-led care in the management of rheumatoid arthritis and psoriatic arthritis (StaerkeR): study protocol for a multi-center randomized controlled trial

BackgroundIn Germany, the care of patients with inflammatory arthritis could be improved. Although specialized rheumatology nurses could take over substantial aspects of patient care, this hardly occurs in Germany. Thus, the aim of the study is to examine structured nursing consultation in rheumatology practices.Methods/designIn total, 800 patients with a stable course of rheumatoid arthritis or psoriatic arthritis in 20 centers in North Rhine–Westphalia and Lower Saxony will be randomized to either nurse-led care or standard care. Participating nurses will study for a special qualification in rheumatology and trial-specific issues. It is hypothesized that nurse-led care is non-inferior to standard care provided by rheumatologists with regard to a reduction of disease activity (DAS28) while it is hypothesized to be superior regarding changes in health-related quality of life (EQ-5D-5L) after 1 year. Secondary outcomes include functional capacity, patient satisfaction with treatment, and resource consumption.DiscussionSince there is insufficient care of rheumatology patients in Germany, the study may be able to suggest improvements. Nurse-led care has the potential to provide more efficient and effective patient care. This includes a more stringent implementation of the treat-to-target concept, which may lead to a higher percentage of patients reaching their treatment targets, thereby improving patient-related outcomes, such as quality of life, functional capacity, and participation. Additionally, nurse-led care may be highly cost-effective. Finally, this project may form the basis for a sustainable implementation of nurse-led care in standard rheumatology care in Germany.Trial registrationGerman Clinical Trials Register, DRKS00015526. Registered on 11 January 2019.

Characteristics of patients treated by the Danish Helicopter Emergency Medical Service from 2014-2018: a nationwide population-based study

BackgroundA national Helicopter Emergency Medical Service (HEMS) was introduced in Denmark in 2014 to ensure the availability of physician-led critical care for all patients regardless of location.Appropriate dispatch of HEMS is known to be complex, and resource utilisation is a highly relevant topic. Population-based studies on patient characteristics are fundamental when evaluating and optimising a system. The aim of this study was to describe the patient population treated by the Danish HEMS in terms of demographics, pre-hospital diagnostics, severity of illness or injury, and the critical care interventions performed.MethodThe study is a retrospective nationwide population-based study based on data gathered from the Danish HEMS database. We included primary missions resulting in a patient encounter registered between October 1st 2014 and April 30th 2018.ResultsOf 13.391 dispatches registered in the study period we included 7133 (53%) primary missions with patient encounter: 4639 patients were air lifted to hospital, 174 patients were escorted to hospital by the HEMS physician in an ambulance, and in 2320 cases HEMS assisted the ground crew on scene but did not escort the patient to hospital. Patient age ranged from 0-99 years and 64% of the population were men. The median age was 60 years.The main diagnostic groups were cardio-vascular emergencies (41%), trauma (23%) and neurological emergencies (16%). In 61% of the cases, the patient was critically ill/injured corresponding to a NACA (National Advisory Committee for Aeronautics) score between 4 and 7 (both included). In more than one third of the missions a critical care intervention was performed. Ultrasound examination and endo-tracheal intubation were the critical care interventions most frequently performed (21% and 20%, respectively).ConclusionThe national Danish HEMS primarily attends severely ill or injured patients and often perform critical care interventions. In addition, the Danish HEMS provides rapid transport to highly specialised treatment for patients in the more rural parts of the country.Patients with cardio-vascular emergencies, trauma and neurological emergencies are among those patient groups most commonly seen.We conclude that the overall dispatch profile appears appropriate but emphasise that continuous development and refinement is essential.