Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts.

BACKGROUND: There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use. OBJECTIVE: To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety. METHODS: This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design. RESULTS: Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death. CONCLUSIONS: GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.

Referral for specialized health services is a key part of the general practitioner (GP) role. Differences in referrals between primary care physicians have been widely studied, as they represent a target for reducing the use of specialized health services. However, the potential consequences beyond the actual referral have received little attention. Studying associations between physician characteristics and clinical decisions are difficult because physicians often systematically see different patient populations with different morbidity. Previous findings showing large differences in clinical decisions regarding referrals and hospital admissions may suffer from confounding. With our carefully matched study design, we could assume that the assignment of physicians to patients was random. We found substantial differences in referrals associated with GP characteristics. Seeing older and male GPs and specialists in family medicine were associated with fewer immediate unplanned hospital admissions but did not substantially influence unplanned hospital costs within 30 days. However, GPs with a history of admitting many of their recent patients had a substantial higher tendency to admit their future patients and represented a higher use of health services and costs. These GPs also referred more critically ill patients, an essential aspect of patient safety. The differences in referrals had minor impact on the patients' 30-day risk of death.

Long-term changes in body weight and physical activity in relation to all-cause and cardiovascular mortality: the HUNT study.

BACKGROUND: Most previous studies have relied on single measurements of body weight and physical activity and have not considered the interplay between long-term changes in body weight and physical activity in relation to mortality. The aim of the current study was therefore to examine the joint effect of changes in body weight and leisure-time physical activity over a period of ~ 10 years on all-cause and cardiovascular mortality. METHODS: The study population comprised 34,257 individuals who participated in the first (1984-86) and second (1995-97) waves of the HUNT Study, and were followed up through the Norwegian Cause of Death Registry until December 31st, 2013. We used Cox regression to estimate hazard ratios (HR) with 95% confidence intervals (CI) of death associated with changes in body weight and leisure-time physical activity. RESULTS: Compared to the reference group with stable weight who were long-term physically active, people who gained ≥5% of their weight had a HR for all-cause mortality of 1.54 (95% CI: 1.28-1.85) if they were long-term physically inactive; a HR of 1.23 (1.09-1.40) if they became physically active, and a HR of 1.00 (95% CI 0.94-1.06) if they were long-term physically active. The corresponding HRs for cardiovascular mortality were 1.57 (95% CI 1.17-2.12), 1.28 (95% CI 1.04-1.58) and 1.06 (95% CI 0.96-1.16), respectively. Long-term physical inactivity was associated with increased all-cause (HR 1.29; 95% CI 1.08-1.53) and cardiovascular (HR 1.37; 95% CI 1.05-1.79) mortality among those who were weight stable. CONCLUSIONS: The risk of all-cause and cardiovascular mortality is particularly evident among people who gain weight while remaining inactive during a ~ 10 year period. However, participants who remained physically active had the lowest risk of premature mortality, regardless of maintenance or increase in weight. These findings suggest that there is an interplay between long-term changes in body weight and physical activity that should receive particular attention in the prevention of premature mortality.

Increasing workload in Norwegian general practice - a qualitative study.

BACKGROUND: General practitioners (GPs) play a key role in securing and coordinating appropriate use of healthcare services, by providing primary and preventive healthcare and by acting as gatekeepers for secondary healthcare services. Historically, European GPs have reported high job satisfaction, attributed to high autonomy and good compatibility with family life. However, a trend of increasing workload in general practice has been seen in several European countries, including Norway, leading to recruitment problems and concerns about the well-being of both GPs and patients. This qualitative interview study with GPs and their co-workers aims to explore how they perceive and tackle their workload, and their experiences and reflections regarding explanations for and consequences of increased workload in Norwegian general practice. METHODS: We conducted seven focus groups and four individual interviews with GPs and their co-workers in seven GPs' offices in Mid-Norway: three in rural locations and four in urban locations. Our study population consisted of 21 female and 12 male participants; 23 were GPs and 10 were co-workers. The interviews were analysed using systematic text condensation. RESULTS: The analysis identified three main themes: (1) Heavy and increasing workload - more trend than fluctuation?; (2) Explanations for high workload; (3) Consequences of high workload. Our findings show that both GPs and their co-workers experience heavy and increasing workload. The suggested explanations varied considerably among the GPs, but the most commonly cited reasons were legislative changes, increased bureaucracy related to documentation and management of a practice, and changes in patients' expectations and help-seeking behaviour. Potential consequences were also perceived as varying, especially regarding consequences for patients and the healthcare system. The participants expressed concerns for the future, particularly in regards to GPs' health and motivation, as well as the recruitment of new GPs. CONCLUSIONS: This study found heavy and increasing workload in general practice in Norway. The explanations appear to be multi-faceted and many are difficult to reverse. The GPs expressed worries that they will not be able to provide the population with the expected care and services in the future.

Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study.

OBJECTIVES: To estimate the impact of altering referral thresholds from out-of-hours services on older patients' further use of health services and risk of death. DESIGN: Cohort study using patient data from primary and specialised health services and demographic data from Statistics Norway and the Norwegian Cause of Death Registry. SETTING: Norway PARTICIPANTS: 491 653 patients aged 65 years and older contacting Norwegian out-of-hours services between 2008 and 2016. ANALYSIS: Multivariable adjusted and instrumental variable associations between referrals to hospital from out-of-hours services and further health services use and death for up to 6 months.Physicians' proportions of acute referrals of older, unknown patients from out-of-hours work were used as an instrumental variable ('physician referral preference') for their threshold of referral for such patients whose clinical presentations were less clear cut. RESULTS: For older patients, whose referrals could be attributed to their physicians' threshold for referral, mean length of stay in hospital increased 3.30 days (95% CI 3.13 to 3.27) within the first 10 days, compared with non-referred patients. Such referrals also increased 6 months use of outpatient specialist clinics and primary care physicians. Importantly, patients with referrals attributable to their physicians' threshold had a substantially reduced risk of death the first 10 days (HR 0.53, 95% CI 0.31 to 0.91), an effect sustaining through the 6-month follow-up period (HR 0.72, 95% CI 0.54 to 0.97). CONCLUSIONS: Out-of-hours patients whose referrals are affected by physician referral threshold contribute substantially to the use of health services. However, the referral seems protective by reducing the risk of death in the first 6 months after the referral. Thus, raising the threshold for referral to lower pressure on overcrowded emergency departments and hospitals should not be encouraged without ensuring the accuracy of the referral decisions, ideally through high-quality randomised controlled trial evidence.

Assessment of bone marrow lymphocytic status during tyrosine kinase inhibitor therapy and its relation to therapy response in chronic myeloid leukaemia.

PURPOSE: Tyrosine kinase inhibitors (TKIs) used in the treatment of chronic myeloid leukaemia have been reported to induce immunomodulatory effects. We aimed to assess peripheral blood (PB) and bone marrow (BM) lymphocyte status at the diagnosis and during different TKI therapies and correlate it with treatment responses. METHODS: BM and PB samples were acquired from 105 first-line TKI-treated patients. Relative number of BM lymphocytes was evaluated from MGG-stained BM aspirates, and immunophenotypic analyses were performed with multicolour flow cytometry. RESULTS: Early 3-month expansion of BM lymphocytes was found during all different TKIs (imatinib n = 71, 20 %; dasatinib n = 25, 21 %; nilotinib n = 9, 22 %; healthy controls n = 14, 12 %, p < 0.0001). Increased PB lymphocyte count was only observed during dasatinib therapy. The BM lymphocyte expansion was associated with early molecular response; patients with 3-month BCR-ABL1 <10 % showed higher lymphocyte counts than patients with BCR-ABL1 >10 % (23 vs. 17 %, p < 0.05). Detailed phenotypic analysis showed that BM lymphocyte expansion consisted of various lymphocyte subclasses, but especially the proportion of CD19+ B cells and CD3negCD16/56+ NK cells increased from diagnostic values. During dasatinib treatment, the lymphocyte balance in both BM and PB was shifted more to cytotoxic direction (increased CD8+CD57+ and CD8+HLA-DR+ cells, and low T regulatory cells), whereas no major immunophenotypic differences were observed between imatinib and nilotinib patients. CONCLUSIONS: Early BM lymphocytosis occurs with all current first-line TKIs and is associated with better treatment responses. PB and BM immunoprofile during dasatinib treatment markedly differs from both imatinib- and nilotinib-treated patients.