Age-related differences in motives for contacting out-of-hours primary care: a cross-sectional questionnaire study in Denmark.

OBJECTIVE: Demands for out-of-hours primary care (OOH-PC) services are increasing. Many citizens call because of non-urgent health problems. Nevertheless, the patients' motives for requesting medical help outside office hours remains an understudied area. This study aimed to examine motives for calling OOH-PC services in various age groups. DESIGN: Cross-sectional paper based questionnaire study conducted during two weeks in 2015. SETTING: The OOH-PC services in two Danish regions. SUBJECTS: Randomly selected patients calling the two healthcare services and accepting to participate in the study received a questionnaire on patient characteristics, health problems, and 26 pre-defined motives based on the Andersen Behavioural Model. Multivariate regression analyses were conducted for various age groups to calculate the probability of each motive to be a significant factor for the decision to call. RESULTS: A total of 1,871 patients were included in the study; half were parents of children aged 0-12 years. Young adults (18 to 39 years) differed significantly from other age groups as they more often stated perceived barriers and benefits such as "Own GP no time available soon enough" and "Need for quick help because of work". CONCLUSION: Young adults more often perceive barriers and benefits, which may suggest af difference in expectations regarding the purpose of out-of-hours services and accessibility. Further research is needed to address this issue and further explore the potential gap between the citizens' expectations to the OOH-PC services and the prevailing health policies. Key points The out-of-hours primary healthcare services are increasingly contacted for non-urgent problems, but little is known about the citizens' motives for calling. Age is associated with differences in the perceived importance of various motives for calling out-of-hours care. Young adults are more often than other age groups motivated to call due to logistical issues, such as their job.

Patient motives for contacting out-of-hours care in Denmark: a cross-sectional study.

BACKGROUND: Patients in need of acute health care do not always contact the most suitable health care service provider. Contacting out-of-hours primary care for an urgent problem may delay care, whereas contacting emergency medical services for a non-urgent problem could ultimately affect patient safety. More insight into patient motives for contacting a specific health care provider may help optimise patient flows. This study aims to explore patient motives for contacting out-of-hours primary care and the emergency medical services in Denmark. METHODS: We conducted a cross-sectional observational study by sending a questionnaire to patients contacting out-of-hours primary care and emergency medical services, both of which can be directly contacted by patients, in two of five Danish regions in 2015. As we aimed to focus on the first access point, the emergency department was not included. The questionnaire included items on patient characteristics, health problem and 26 pre-defined motives. Descriptive analyses of patient characteristics and motives were conducted, stratified by the two health care service providers. Factors associated with contacting each of the two service providers were explored in a modified Poisson regression analysis, and adjusted risk ratios were calculated. RESULTS: Three key motives for contacting the two service providers were identified: 'unpleasant symptoms', 'perceived need for prompt action' and 'perceived most suitable health care provider'. Other important motives were 'need arose outside office hours' and 'wanted to talk to a physician' (out-of-hours primary care) and 'expected need for ambulance' and 'worried' (emergency medical services). Higher probability of contacting the emergency medical services versus out-of-hours primary care was seen for most motives relating to own assessment and expectations, previous experience and knowledge, and own needs and wishes. Lower probability was seen for most motives relating to perceived barriers and benefits. CONCLUSIONS: Patient motives for contacting the two health care service providers were partly overlapping. The study contributes with new knowledge on the complex decision-making process of patients in need of acute health care. This knowledge could help optimise existing health care services, such as patient safety and the service level, without increasing health care costs.

Comparison of Acute Versus Subacute Coronary Angiography in Patients With NON-ST-Elevation Myocardial Infarction (from the NONSTEMI Trial).

The optimal timing of coronary angiography (CAG) in high-risk patients with acute coronary syndrome without persisting ST-segment elevation (NST-ACS) remains undetermined. The NON-ST-Elevation Myocardial Infarction trial aimed to compare outcomes in NSTE-ACS patients randomized to acute CAG (STEMI-like approach) with patients randomized to medical therapy and subacute CAG. We randomized 496 patients with suspected NST-ACS based on symptoms and significant regional ST depressions and/or elevated point-of-care troponin T (POC-cTnT) (≥50 ng/l) to either acute CAG (<2 hours, n = 245) or subacute CAG (<72 hours, n = 251). The primary end point was a composite of all-cause death, reinfarction, and readmission with congestive heart failure within 1 year from randomization. A final acute coronary syndrome (ACS) diagnosis was assigned to 429 (86.5%) patients. The median time from randomization to revascularization was 1.3 hours in the acute CAG group versus 51.1 hours in the subacute CAG group (p <0.001). The composite end point occurred in 25 patients (10.2%) in the acute CAG group and 29 (11.6%) in the subacute CAG group, p = 0.62. The acute CAG group had a 1-year all-cause mortality of 5.7% compared with 5.6% in the subacute CAG group, p = 0.96. In conclusion, neither the composite end point of all-cause death, reinfarction, and readmission with congestive heart failure nor mortality differed between an acute and subacute CAG approach in NSTE-ACS patients. However, identification of NSTE-ACS patients in the prehospital phase and direct triage to an invasive center is feasible, safe and may facilitate early diagnosis and revascularization.

Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction.

OBJECTIVE: The purpose of this study was to determine the predictive value of routine prehospital point-of-care cardiac troponin T measurement for diagnosis and risk stratification of patients with suspected acute myocardial infarction. METHODS AND RESULTS: All prehospital emergency medical service vehicles in the Central Denmark Region were equipped with a point-of-care cardiac troponin T device (Roche Cobas h232) for routine use in all patients with a suspected acute myocardial infarction. During the study period, 1 June 2012-30 November 2015, prehospital point-of-care cardiac troponin T measurements were performed in a total of 19,615 cases seen by the emergency medical service and 18,712 point-of-care cardiac troponin T measurements in 15,781 individuals were matched with an admission. A final diagnosis of acute myocardial infarction was confirmed in 2187 cases and a total of 2150 point-of-care cardiac troponin T measurements (11.0%) had a value ≥50 ng/l, including 966 with acute myocardial infarction (sensitivity: 44.2%, specificity: 92.8%). Patients presenting with a prehospital point-of-care cardiac troponin T value ≥50 ng/l had a one-year mortality of 24% compared with 4.8% in those with values <50 ng/l, log-rank: p<0.001. The following variables showed the strongest association with mortality in multivariable analysis: point-of-care cardiac troponin T≥50 ng/l (hazard ratio 2.10, 95% confidence interval: 1.90-2.33), congestive heart failure (hazard ratio 1.93, 95% confidence interval: 1.74-2.14), diabetes mellitus (hazard ratio 1.42, 95% confidence interval: 1.27-1.59) and age, one-year increase (hazard ratio 1.08, 95% confidence interval: 1.08-1.09). CONCLUSIONS: Patients with suspected acute myocardial infarction and a prehospital point-of-care cardiac troponin T ≥50 ng/l have a poor prognosis irrespective of the final diagnosis. Routine troponin measurement in the prehospital setting has a high predictive value and can be used to identify high-risk patients even before hospital arrival so that they may be re-routed directly for advanced care at an invasive centre.

Acute pain in the prehospital setting: a register-based study of 41.241 patients.

BACKGROUND: Acute pain is a frequent symptom, but little is known about the frequency and causes of acute pain in the prehospital population. The objectives of this study were to investigate the frequency of moderate to severe pain among prehospital patients and the underlying causes according to primary hospital diagnose codes. METHODS: This was a register-based study on 41.241 patients transported by ambulance. Information on moderate to severe pain [Numeric Rating Scale (NRS, 0-10) > 3 or moderate pain or higher on 4-point likert scale] was extracted from a national electronic prehospital patient record. Patient information was merged with primary hospital diagnose codes based on the 10th version of the International Classification of Diseases (ICD-10) to investigate underlying causes of pain. RESULTS: 11.430 patients (27.7%) reported moderate to severe pain during ambulance transport. As a measure of opioid demanding acute pain, 3.275 of 41.241 patients (7.9%) were treated with intravenous fentanyl. Underlying causes of pain were heterogenic according to ICD-10 chapters with injuries being the largest group of patients with moderate to severe pain (XIX: 42.8% of 8.041 patients), followed by non-specific diagnoses (XVIII: 28.5% of 7.101 patients and XXI: 31.6% of 5.148 patients), diseases of the circulatory system (IX: 22.1% of 4.812 patients) and other (20.3% of 16.139 miscellaneous patients). DISCUSSION: Due to the high frequency of moderate to severe pain affecting a wide range of patients, more attention on acute pain is necessary. Whether ambulance personnel have sufficient options for treating various pain conditions might be a subject of future evaluation. Non-specific diagnoses accounted for surprisingly many patients with moderate to severe pain, of which many were treated with intravenous fentanyl. This may be substance of further investigation. CONCLUSIONS: Moderate to severe pain is a highly frequent and probably underestimated symptom among patients transported by ambulance. Underlying causes of pain are heterogenic as described by primary hospital diagnose codes. More focus on the treatment of acute pain is needed.

Telemedicine-based physician consultation results in more patients treated and released by ambulance personnel.

OBJECTIVE: We examined whether teleconsultation from ambulances to a physician at an emergency medical communication center (EMCC) would increase the proportion of patients with nonurgent conditions being treated and released on site. METHODS: This research was a before-after pilot study. In the intervention period, the EMCC was manned 24/7 with physicians experienced in emergency care. Eligible participants included all patients with nonurgent conditions receiving an ambulance after a medical emergency call. Ambulance personnel assessed patients and subsequently performed a telephone consultation from the ambulance with the physician. The primary outcome was the proportion of patients treated and released on site. Secondary outcomes were the number of hospital admissions, mortality, and patient satisfaction. The intervention period was compared with a corresponding control period from the previous year. RESULTS: We observed an increase in the proportion of patients treated and released in the intervention period in 2014 compared with the control period in 2013, up from 21% (n=137) to 29% (n=221) (odds ratio=1.46; 95% confidence interval=1.14-1.89, P=0.002). The follow-up rate was 100%. There was no observable increase in hospital admissions or mortality among patients treated and released from 2013 to 2014. A telephone survey of patients treated and released showed that 98.4% (95% confidence interval=91.3-99.9) were very satisfied or satisfied with their treatment. CONCLUSION: Teleconsultation between a physician at the EMCC and ambulance personnel and noncritically ill 1-1-2 patients results in an increased rate of patients treated and released with high satisfaction. The approach does not seem to compromise patient safety.

The change in nasal inflammatory markers after intranasal challenges with particulate chitin and lipopolysaccharide: a randomized, double-blind, placebo-controlled, crossover study with a positive control.

BACKGROUND: We investigated the effect of chitin on the inflammation and immune modulation of the nasal mucosa. This compound was compared to placebo and as a positive control we used lipopolysaccharide (LPS). METHODS: Fourteen healthy nonsmoking volunteers 22 to 28 years of age were included. All persons underwent exposure to chitin microparticles (CP) and placebo in a randomized double-blinded fashion. In a last session we used LPS from Enterobacter agglomerans in a single-blinded fashion. There were 2 weeks between each session. The outcome measures were Total Nasal Symptom Score (TNSS) and nasal lavage for cytokines and cells at 0, 3, 4, 8 hours. RESULTS: We showed that CP was only weakly inflammatory compared to LPS. In contrast to the LPS response, we did however show an immune-regulatory effect of CP on enhanced interleukin (IL)-4 and IL-6 responses known to downregulate T helper 2 (Th2) responses, indicating a potential beneficial effect of CP for the regulation of the allergic Th2 immune response. CONCLUSION: This study also shows that CP is well tolerated in healthy volunteers, and that does not induce significantly more symptoms compared to placebo. In fact there is a tendency for CP instillation to induce less rhinorrhoea compared to placebo.

Continuous positive airway pressure and noninvasive ventilation in prehospital treatment of patients with acute respiratory failure: a systematic review of controlled studies.

Continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are frequently used inhospital for treating respiratory failure, especially in treatment of acute cardiogenic pulmonary edema and exacerbation of chronic obstructive pulmonary disease. Early initiation of treatment is important for success and introduction already in the prehospital setting may be beneficial. Our goal was to assess the evidence for an effect of prehospital CPAP or NIV as a supplement to standard medical treatment alone on the following outcome measures; mortality, hospital length of stay, intensive care unit length of stay, and intubation rate. We undertook a systematic review based on a search in the three databases: PubMed, EMBASE, and Cochrane. We included 12 studies in our review, but only four of these were of acceptable size and quality to conclude on our endpoints of interest. All four studies examine prehospital CPAP. Of these, only one small, randomized controlled trial shows a reduced mortality rate and a reduced intubation rate with supplemental CPAP. The other three studies have neutral findings, but in two of these a trend toward lower intubation rate is found. The effect of supplemental NIV has only been evaluated in smaller studies with insufficient power to conclude on our endpoints. None of these studies have shown an effect on neither mortality nor intubation rate, but two small, randomized controlled trials show a reduction in intensive care unit length of stay and a trend toward lower intubation rate. The risk of both type two errors and publication bias is evident, and the findings are not consistent enough to make solid conclusion on supplemental prehospital NIV. Large, randomized controlled trials regarding the effect of NIV and CPAP as supplement to standard medical treatment alone, in the prehospital setting, are needed.

No effect of TETRA hand portable transmission signals on human cognitive function and symptoms.

Current radio frequency radiation exposure guidelines rest on well-established thermal effects. However, recent research into analogue and digital transmission fields at levels covered by the exposure guidelines has indicated possible detrimental effects on human cognitive performance. To investigate this, we conducted a controlled climate chamber study of possible changes in cognitive performance in healthy volunteers exposed to transmission signals from TETRA hand portables (TETRA handsets). The trial deployed a balanced, randomized, double-blinded cross-over design. Performance on different paper-and-pencil, auditory and computer-based cognitive tasks was monitored in 53 male volunteers (mean age 36.41 years, SD 8.35) during 45-min exposure to a TETRA handset and sham control signals remotely controlled from a laboratory more than 100 km away. The main cognitive outcome was the Trail Making B (TMB) test. In addition, the participants completed a computer-based questionnaire measuring self-reported psychological and physical symptoms. No statistically significant differences (P < 0.05) between the TETRA and sham conditions were found for either TMB (estimated difference 3.8%, confidence interval (CI) -1.6% to 9.2%) or any of the remaining cognitive tasks or symptoms. In conclusion, we found no evidence that brief exposure to hand-held TETRA transmitters' affects human cognitive function or subjective symptoms.

Cognitive function and symptoms in adults and adolescents in relation to rf radiation from UMTS base stations.

There is widespread public concern about the potential adverse health effects of mobile phones in general and their associated base stations in particular. This study was designed to investigate the acute effects of radio frequency (RF) electromagnetic fields (EMF) emitted by the Universal Mobile Telecommunication System (UMTS) mobile phone base stations on human cognitive function and symptoms. Forty adolescents (15-16 years) and 40 adults (25-40 years) were exposed to four conditions: (1) sham, (2) a Continuous Wave (CW) at 2140 MHz, (3) a signal at 2140 MHz modulated as UMTS and (4) UMTS at 2140 MHz including all control features in a randomized, double blinded cross-over design. Each exposure lasted 45 min. During exposure the participants performed different cognitive tasks with the Trail Making B (TMB) test as the main outcome and completed a questionnaire measuring self reported subjective symptoms. No statistically significant differences between the UMTS and sham conditions were found for performance on TMB. For the adults, the estimated difference between UMTS and sham was -3.2% (-9.2%; 2.9%) and for the adolescents 5.5% (-1.1%; 12.2%). No significant changes were found in any of the cognitive tasks. An increase in 'headache rating' was observed when data from the adolescents and adults were combined (P = 0.027), an effect that may be due to differences at baseline. In conclusion, the primary hypothesis that UMTS radiation reduces general performance in the TMB test was not confirmed. However, we suggest that the hypothesis of subjective symptoms and EMF exposure needs further research.