Development of the use of primary health care emergency departments after interventions aimed at decreasing overcrowding: a longitudinal follow-up study.

BACKGROUND: This study, conducted in a Finnish city, examined whether decreasing emergency department (ED) services in an overcrowded primary care ED and corresponding direction to office-hours primary care would modify service usage for specific gender, age or diagnosis groups. METHODS: This was an observational retrospective study carried out by gradually decreasing ED services in primary care. The interventions aimed at decreasing use of EDs were a) application of ABCDE-triage combined with public guidance on the proper use of EDs, b) closure of a minor supplementary ED, and finally, c) application of "reverse triage" with enhanced direction of the public to office-hours services and away from the remaining ED The annual number of visits to office-hours primary care GPs in different gender, age and diagnosis groups (International Classification of Diseases (ICD - 10) were recorded during a 13-year follow-up period. RESULTS: The total number of monthly visits to EDs decreased slowly over the whole study period. This decrease was similar in women and men. The decrease was stronger in the youngest age groups (0-19 years). GPs treated decreasing proportions of ICD-10 groups. Recorded infectious diseases (Groups A and J, and especially diagnoses related to infections of respiratory airways) tended to decrease. However, visits due to injuries and symptomatic diagnoses increased. CONCLUSION: Decreasing services in a primary health care ED with the described interventions seemed to reduce the use of services by young people. The three interventions mentioned above had the effect of making the primary care ED under study appear to function more like a standard ED driven by specialized health care.

Oral symptoms and oral health-related quality of life in patients with chronic kidney disease from predialysis to posttransplantation.

OBJECTIVE: This prospective follow-up cohort study analyzed chronic kidney disease (CKD) patients' oral symptoms, health habits, and oral health-related quality of life (OHRQoL), from predialysis to posttransplantation. A simplified questionnaire method (Oral Health Quality Score, OHQS), based on these and clinical findings, was constructed and tested for identifying patients in need for referral to a dentist. MATERIAL AND METHODS: Fifty-three CKD patients were followed up for a mean of 10.3 years. Clinical oral, radiological, and salivary examination was performed at baseline and posttransplantation. Total Dental Index (TDI) indicating inflammation was calculated. The patients filled out a questionnaire on symptoms, oral hygiene and health care habits, smoking, alcohol use, and medication. General health-related quality of life was assessed with the 15-dimensional (15D) instrument at posttransplantation. Descriptive and analytical methods were used in statistics. RESULTS: OHQS significantly correlated with high TDI (p = 0.017), number of teeth (p = 0.031), and unstimulated salivary flow rate (p = 0.001) in transplanted patients. Number of daily medications showed a negative correlation with the OHQS (r = - 0.30; p = 0.028). The prevalence of oral symptoms was slightly, but not significantly, more common posttransplantation compared with predialysis stage. CONCLUSION: OHQS identified patients with high oral inflammatory score thus confirming our study hypothesis. CLINICAL RELEVANCE: Use of OHQS and measuring salivary flow indicate patients at risk for oral diseases. These markers might be easy to use chair-side also by auxiliary personnel.

Adherence to individualized recall intervals for oral health examinations.

OBJECTIVES: The aim of this follow-up study was to investigate whether adults attend an oral health examination (OHE) based on their individual recall interval (IRI) without a reminder recall system. METHODS: The study population included adults who were attending an OHE recommended by their dentists based on their IRI in public oral healthcare clinics of Helsinki City January 1, 2009-December 31, 2009. The inclusion criteria were as follows: alive until the end of IRI, length of the IRI of 12-60 months, and study participants had not been treated successfully by a dental specialist during the IRI period (n = 41,255). We used a multinomial model to identify the factors associated with the timing of OHE. The following predictors were included: oral health indices such as Decayed Teeth and the Community Periodontal Index, the length of the IRI based on an OHE in 2009, age, gender, socioeconomic status, presence of chronic diseases, and emergency appointment. Results were presented as odds ratios with 95% confidence intervals. RESULTS: The OHE based on IRI occurred for 7505 individuals (18.2%) and the OHE was late for 9159 individuals (22.2%). A total of 24,591 (59.6%) adults did not undergo follow-up OHE based on the IRI period of on time or late. Those who came on time for follow-up OHE experienced less caries than those who came later. There was not much difference in periodontal health between the groups. The models indicated that having an emergency appointment was associated with a higher probability of having an OHE. A long IRI (37-60 months) was associated with a higher probability of not participating in OHE even late. CONCLUSIONS: It would be beneficial for patients to take appointments based on the recall interval. The results of this study indicated that more needs to be done to increase awareness in the adult population of the benefits and availability of follow-up OHEs based on their IRI in oral healthcare.

Implementing of aMMP-8 point-of-care test with a modified new disease classification in Finnish adolescent cohorts.

OBJECTIVES: Periodontitis is a multifactorial biofilm-induced inflammatory disease; however, clinical and radiographic information reflects events that have already occurred. aMMP-8 lateral-flow chairside or point-of-care-test (POC-test) results have also come to complement the overall status of the patient's current situation. The current study aimed to clarify the usefulness of aMMP-8 chairside-test (aMMP-8 POCT) results to alert the initial or early periodontitis in adolescents, a potential periodontitis risk group with cut off 20 ng/ml in Stage I periodontitis, according to the current periodontitis classification system. MATERIAL AND METHODS: A total of 117 adolescents were aMMP-8 POC tested for aMMP-8 levels and examined for the full mouth and were interviewed for questions concerning health behavior. RESULTS: Of all 117 participants, N = 38 (32.5%) was aMMP-8 POCT positive, and N = 34 (29.1%) had at least one 4 mm periodontal deepened pocket; however, only N = 16 (13.7%) had both characteristics. The subclinical stage (N = 47) could not be classified either as gingivitis or Stage I. Of the participants, who did not have any deepened periodontal pockets, 18  tested negative. CONCLUSIONS: Stage I is preceded by antecedent stages that should be tackled by oral healthcare prevention and personalized treatment modalities by professionals. Elevated (>20 ng/ml), positive aMMP-8 POCT results can be regarded as initial alarmer such as emerging risk. This should be utilized in the preventive personalized interventions by oral health professionals.

Development of office-hours use of primary health centers in the early years of the 21st century: a 13-year longitudinal follow-up study.

This study, conducted in a Finnish city, examined whether a long-lasting observed trend in Finnish primary health care, namely, a decreasing rate of office-hour visits to general practitioners (GPs), would lead to reduced services for specific gender, diagnosis or age groups. This was an observational retrospective follow-up study. The annual number of visits to office-hour primary care GPs in different gender, diagnosis and age groups was recorded during a 13-year follow-up period. The effect of the decreasing visit rate on the annual mortality rate in different age and gender groups was also studied. The total number of monthly visits to office-hour GPs decreased slowly over the whole study period. This decrease was stronger in women and older people. The proportion of recorded infectious diseases (Groups A and J and especially diagnoses related to infections of respiratory airways) decreased. Proportions of recorded chronic diseases increased (Group I, cardiovascular diseases, diabetes and osteoarthrosis) during the follow-up. The annual rate of visits to office-hour GP/per GP decreased. There was a decrease in the mortality in two of the age groups (20-64, 65+ years) and no change in the youngest population (0-19 years). The decrease in the office-hours GP activity does not seem to increase mortality either.

Recording of diagnoses in public primary oral health care in a retrospective longitudinal observational study in a Finnish town: Underrepresentation of periodontitis diagnoses.

OBJECTIVES: This study investigates which oral diagnoses public primary dental care dentists record. METHODS: An observational register-based retrospective follow-up study was performed in the public primary oral health care of a Finnish town after the dentists were advised to mark the diagnoses in their practices. The rate of recorded diagnoses resulting from visits to the public primary care dentists was studied. The assessed diagnoses were recorded with the 10th revision of the International Classification of Diseases. The distribution of diagnoses was recorded during a 2-year follow-up period. RESULTS: The most frequent diagnosis groups were dental caries (K02, 38.6%), other diseases of dental hard tissues (K03, 14.9%), diseases of pulp and periapical tissues (K04, 11.4%), periodontal diseases (K05, 9.7%), and different types of bone fractures (S02, 8.1%). Periodontitis was underrepresented. CONCLUSIONS: In public primary oral health care, there may be difficulties in adequate recording of certain chronic diseases.

The effect of electronic reminders on the recording of diagnoses in primary care: A quasi-experimental before and after study.

Objectives: This study examined whether using electronic reminders leads to an increase in the rate of diagnosis recordings in the electronic health record system following visits to a general practitioner. The impact of electronic reminders was studied in the primary health care of a Finnish city. Methods: This observational quasi-experimental study based on a before-and-after design was carried out by installing an electronic reminder to improve the recording of diagnoses in the computerized electronic health record system. The quantity of the recorded diagnoses was observed before and after the intervention. The effect of this intervention on the distribution of different diagnoses was also studied. Results: Before intervention, 33%-46% of visits (to general practitioners/month) had recorded diagnose in the primary health care units. After 4 years, the recording rate had risen to 87%-95% (p < 0.001). The rate of change in the recording of diagnoses was highest during the first year of intervention and plateaued about 3.5 years after application reminders. In the present study, most of the visits concerned mild respiratory infections, elevated blood pressure, low back pain and type 2 diabetes. Conclusion: An electronic reminder is likely to improve the recording of diagnoses during the visits to general practitioners. The distribution of diagnoses was in line with former reports concerning diagnoses in Finnish primary care.

Improving the Recording of Diagnoses in Primary Care with Team Incentives: A Controlled Longitudinal Follow-Up Study.

INTRODUCTION: We studied whether primary care teams respond to financial group bonuses by improving the recording of diagnoses, whether this intervention leads to diagnoses reflecting the anticipated distribution of diseases, and how the recording of a significant chronic disease, diabetes, alters after the application of these bonuses. METHODS: We performed an observational register-based retrospective quasi-experimental follow-up study with before-and-after setting and two control groups in primary healthcare of a Finnish town. We studied the rate of recorded diagnoses in visits to general practitioners with interrupted time series analysis. The distribution of these diagnoses was also recorded. RESULTS: After group bonuses, the rate of recording diagnoses increased by 17.9% (95% CI: 13.6-22.3) but not in either of the controls (-2.0 to -0.3%). The increase in the rate of recorded diagnoses in the care teams varied between 14.9% (4.7-25.2) and 33.7% (26.6-41.3). The distribution of recorded diagnoses resembled the respective distribution of diagnoses in the former studies of diagnoses made in primary care. The rate of recorded diagnoses of diabetes did not increase just after the intervention. CONCLUSIONS: In primary care, the completeness of diagnosis recording can be, to varying degrees, influenced by group bonuses without guarantee that recording of clinically significant chronic diseases is improved.