Where do GPs seek help for their illnesses? / Hvor søker fastleger hjelp ved egen sykdom?

Background: Doctors generally enjoy good health, but often refrain from seeking help when they are ill. Self-treatment is widespread, and this can be an inappropriate and risky practice. Material and method: This is a registry study that compares GPs' own use of the primary and specialist health services in 2018 with a control group consisting of all others in the same age group with the same sex, level of education and health as the GPs. Morbidity in both groups was surveyed with the aid of two validated morbidity indexes in the period 2015-17. Only those who scored zero on both indexes were included. Results: While only 21.7 % of the GPs had sought help from a GP and 3.3 % had attended the emergency department, the corresponding figures for the control group were 61.6 % and 11.8 %. Of the GPs, 17.5 % consulted a contract specialist, compared to 15.5 % of the control group. Measured as a proportion of all specialist consultations, consultations with a psychiatrist constituted 35 % for GPs and 13 % for others. There were small differences in the use of somatic outpatient clinics (25.9 % of GPs and 25.7 % of the control group) and acute admission in somatic hospitals (3.8 % of GPs and 3.3 % of the control group). Interpretation: This study indicates that GPs receive medical assistance from other than their own GP.

Use of non-specific diagnostic codes in out-of-hours services. / Bruk av uspesifikke diagnosekoder på legevakt.

BACKGROUND: Primary care doctors put diagnostic codes on all reimbursement cards. The objective of this study was to map out the use of non-specific diagnostic codes that can undermine the validity of statistics and disease surveillance. MATERIAL AND METHOD: The material consists of data from all electronic reimbursement cards from out-of-hours services in the period 2008-2019. We registered consultations and telephone contacts and the proportion of these that were supplied with diagnostic codes for respiratory infections and three non-specific diagnostic codes. RESULTS: The number of consultations per year increased from 1 402 452 in 2008 to 1 417 395 in 2019, a relative increase of 1 %. The number of telephone contacts per year increased from 286 515 in 2008 to 684 773 in 2019, a relative increase of 139 %. Out-of-hours contacts coded with non-specific diagnoses increased nearly thirteenfold, from 40 280 to 514 715. The use of non-specific diagnoses increased by a factor of 19 for telephone contacts and 2.7 for consultations. The total number of out-of-hours contacts for respiratory infections decreased from 240 037 to 176 909 (a 26 % reduction). INTERPRETATION: There is a strong tendency for general, non-specific diagnostic codes to replace specific diagnoses of disease on reimbursement cards from out-of-hours services. This undermines the evidence base for statistics and research based on reported ICPC-2 diagnoses, and this is especially of concern when these diagnoses are to be used for monitoring of the COVID-19 pandemic.

Local emergency medical communication centres - staffing and populations. / Legevaktsentralar ­ bemanning og folketal.

BACKGROUND: There are several examples of inadequate staffing at local emergency medical communication centres (LEMCs) resulting in limited availability and long waits on the telephone. There are no guidelines for population size or the staffing of a LEMC. In the following, we present models of catchment areas and staffing. MATERIAL AND METHOD: Traffic intensity on Saturdays and Sundays was based on data on figures for patient contacts at seven LEMCs in 2014 and 2015. We defined the minimum optimal population base as at least 50 % probability of ≥ 10 contacts in the course of a night duty. The Erlang-C formula was used to estimate service level and hence staffing requirements on the basis of population and response-time requirements. We have surveyed the combined staffing requirements of all the LEMCs in Norway. RESULT: The minimum optimal population base was 29 134. In 2016, 48 of 103 LEMCs were smaller than this. In order to be able to satisfy the response-time requirements in the Norwegian Emergency Medicine Regulations, 112 LEMC night operators and 158 day operators would be necessary for the whole of Norway. A reduction of the response-time requirement from 120 to ten seconds would require 9.8 % more operators at night and 17 % more operators during the day. INTERPRETATION: The models we have presented provide a basis for planning the population base and staffing of LEMCs. Significantly stricter response-time requirements will result in limited need for more personnel.

Contacts with out-of-hours services because of poisonings in Norway 2006 - 15. / Legevaktkontakter på grunn av forgiftning i Norge 2006 ­ 15.

BACKGROUND: Poisonings constitute a serious health problem in Norway. The objective of the study was to analyse cases of poisoning reported to out-of-hours services and any changes that may have occurred over a ten-year period. MATERIAL AND METHOD: The material consists of reimbursement claims from all doctors on out-of-hours duty in Norway in the period 2006 ­ 15. Poisonings were defined as ICPC diagnostic codes A84 (poisoning by medical agent), A86 (toxic effect non-medicinal substance) or P16 (acute alcohol abuse). RESULTS: The contact rate due to poisonings increased from 221 per 100 000 inhabitants in 2006 to 297 per 100 000 inhabitants in 2015. For the age group 1 ­ 2 years, the contact rate per 100 000 inhabitants dropped from 469 to 223, for the age group 15 ­ 25 it rose from 523 to 719, and for the age group 53 ­ 59 it rose from 178 to 339. The highest contact rate was found among women aged 15 ­ 25 (785 per 100 000 inhabitants). This group also had the highest contact rate caused by poisoning by a medical agent (238 per 100 000 inhabitants). In the age group 15 ­ 25 years, altogether 63% of the poisonings occurred during the night. INTERPRETATION: The frequency of contact with out-of-hours services because of poisoning is generally increasing, although a strong decline is observed among small children. Adolescents, and young women in particular, stand out in suffering frequent cases of poisoning.

Out-of-hours doctors' decisions on call-outs in emergency situations.

BACKGROUND: Several earlier studies have shown that doctors in local out-of-hours emergency primary health care participate in call-outs to varying degrees. It is the out-of-hours doctor who decides whether to respond with a call-out. We wished to study the assessments that form the basis of this decision. MATERIAL AND METHOD: We interviewed the out-of-hours doctors in the county of Hordaland who had been alerted about an emergency incident on the health radio network during an evening or night shift, apart from at weekends. The interview period lasted from July to October 2012 and was linked directly to specific alarm calls. RESULTS: There were 252 relevant incidents, 72 of which were investigated. A total of 47 of the 95 doctors contacted were interviewed (49%). The doctor responded with a call-out in 65 % of the incidents. Normally it was the content of the message about the patient's medical condition that was critical for the doctor's decision to respond with a call-out, while it was most often practical aspects that meant that she/he did not respond in this way. When the doctor responded with a call-out, and later assessed the call-out as necessary, the patient's need for medical expertise was the most important reason given. INTERPRETATION: In the incidents studied, the decision on whether or not to respond with a call-out was based on a balanced consideration of the patient's needs and what was practically possible for the doctor. The out-of-hours doctors experienced a need for medical expertise in many emergency medical situations.

[Travel time and distances to Norwegian out-of-hours casualty clinics]. / Reisetid og avstand til norske legevakter.

BACKGROUND: Geographical factors have an impact on the utilisation of out-of-hours services. In this study we have investigated the travel distance to out-of-hours casualty clinics in Norwegian municipalities in 2011 and the number of municipalities covered by the proposed recommendations for secondary on-call arrangements due to long distances. MATERIAL AND METHOD: We estimated the average maximum travel times and distances in Norwegian municipalities using a postcode-based method. Separate analyses were performed for municipalities with a single, permanently located casualty clinic. Altogether 417 out of 430 municipalities were included. We present the median value of the maximum travel times and distances for the included municipalities. RESULTS: The median maximum average travel distance for the municipalities was 19 km. The median maximum average travel time was 22 minutes. In 40 of the municipalities (10 %) the median maximum average travel time exceeded 60 minutes, and in 97 municipalities (23 %) the median maximum average travel time exceeded 40 minutes. The population of these groups comprised 2 % and 5 % of the country's total population respectively. For municipalities with permanent emergency facilities(N = 316), the median average flight time 16 minutes and median average distance 13 km.. INTERPRETATION: In many municipalities, the inhabitants have a long average journey to out-of-hours emergency health services, but seen as a whole, the inhabitants of these municipalities account for a very small proportion of the Norwegian population. The results indicate that the proposed recommendations for secondary on-call duty based on long distances apply to only a small number of inhabitants. The recommendations should therefore be adjusted and reformulated to become more relevant.

[Travel distance and the utilisation of out-of-hours services]. / Reiseavstand og bruk av legevakt.

BACKGROUND: It has been documented from a number of out-of-hours primary health care services that the utilisation of the services declines with increasing travel distances. In this study we have investigated the correlation between travel distances and the use of out-of-hours medical services for all Norwegian municipalities that provide such services at a single permanent casualty clinic round the clock. In addition, we have sought to reveal any differences in consultation rates between municipalities that maintain single-municipality or inter-municipal out-of-hours services, as well as between municipalities in which the casualty clinics are co-located with a hospital or located separately. MATERIAL AND METHOD: Information on the types of out-of-hours services existing in 2011 was retrieved from the Norwegian Emergency Primary Health Care Registry, and 315 municipalities with single permanent casualty clinic premises were included. Rates for various types of utilisation of these clinics were calculated on the basis of statistics generated from reimbursement claims. RESULTS: The number of medical consultations and house calls per inhabitant fell by 48 % and 55 % respectively when average travel distance increased from 0 to 50 kilometres. The use of telephone/letter contact was not significantly associated with distances. Single-municipality casualty clinics located outside hospitals had the highest consultation rate for out-of-hours medical services when adjusted for distance. INTERPRETATION: This supports previous findings to the fact that distance is a crucial factor for the utilisation of out-of-hours medical services. Establishing inter-municipal casualty clinics and co-locating them with hospitals may contribute to a lower rate of use of out-of-hours medical services.

Prescriptions for ADHD medication, 2004-08.

BACKGROUND: The use of medication for ADHD has increased significantly since the 1990 s. The objective of this study was to establish the prescription rate for such drugs in Norway, and to examine which doctors prescribe them. MATERIAL AND METHOD: Data relating to all ADHD medication collected in the period 2004-08 was obtained from the Norwegian Prescription Database and linked to the GP database. RESULTS: The number of people who collected at least one prescription annually for ADHD medication increased over the period, while the number of new drug users remained stable. In 2008, 3.6 % of the boys and 1.2 % of the girls aged 11-15 collected their prescriptions. Of the people who collected their prescriptions for the first time in 2005, 53 % continued to collect prescriptions every year throughout the period 2006-08. In 2008, extended-release methylphenidate constituted 51 % of the prescription volume for adults and 83 % for children and young people. GPs prescribed 17 % of the total volume collected in 2004 and 48 % in 2008. INTERPRETATION: During childhood and the teenage years there are substantial differences between the sexes when it comes to the prescription pick-up rate for ADHD medication. This may suggest that girls who suffer from ADHD go through large parts of their statutory education before they are diagnosed and receive treatment. GPs play an important role in the treatment of ADHD.

Use of emergency medical services by patients encompassed by the Regular GP scheme.

BACKGROUND: Norwegian emergency medical services are used with frequency, often in relation to conditions that could wait until the next day to be handled by the patient's regular GP (RGP). We investigated whether there are characteristics of particular GPs that may help explain why patients on their list use the emergency medical services. MATERIAL AND METHODS: We used data from the billing cards for 2008 from all emergency doctors, linked to information from the Regular GP database and Statistics Norway, for a total of 4,097 RGPs. For each RGP we estimated a contact rate: The total number of contacts reported for their list patients (identified by their personal ID numbers), divided by the length of the RGP's list. This rate was subsequently analysed with regard to characteristics of the RGP (bivariate analyses and multiple logistic regression). RESULTS: The average contact rate amounted to 27.4 contacts per 100 list patients, with significant variation between the RGPs (the 25th percentile was 17.8 contacts and the 75th percentile 33.1). Patients of male RGPs, young RGPs and immigrant RGPs used the emergency medical services more frequently than patients of female RGPs, older RGPs and Norwegian RGPs. Patients from long lists, single-doctor practices and open lists used the emergency medical services less frequently than patients from short lists, group practices and closed lists. The contact rate was higher in rural municipalities than in urban areas. INTERPRETATION: The large variations in the use of emergency medical services indicate that more RGPs should take measures to improve accessibility for emergency calls during the daytime.

Which GPs are staffing the emergency medical services?

BACKGROUND: Approximately half of all accident and emergency medical (A&E) services are provided by regular general practitioners (RGPs). We wished to find out which RGPs staff the A&E services. MATERIAL AND METHOD: The material comprises billing cards from all A&E doctors in 2008, linked to information from Statistics Norway and the Regular GP database. We estimated the proportion of various RGPs who staff the A&E roster and how many patient contacts they had while on duty. The same variables describing the RGPs were used in a multivariate logistic regression analysis, in which the dependent variable was whether the RGPs were on the emergency service roster or not. RESULTS: Altogether 53% of the RGPs were on the emergency service roster, and accounted for 47% of all patient contacts. The RGPs were older than other emergency doctors (44 years as opposed to 34 years), and included a smaller proportion of women (33% as opposed to 44%). Immigrants accounted for 23% of the RGPs and 21% of the other emergency doctors. Women RGPs were on A&E duty less frequently than their male counterparts in all age groups, and they also had fewer patient contacts (206 and 374). The participation rate decreased in proportion to the doctors' age, increasing list length and increasing centrality. Immigrant RGPs with a short time of residence in Norway had the highest frequency of on-call duty (81%). INTERPRETATION: The number of women RGPs is increasing, and it is therefore likely that the frequency of on-call duty among RGPs will decrease further. However, the immigrants are providing a significant contribution to maintaining the A&E scheme.

[The influenza pandemic in a Norwegian municipality autumn 2009]. / Influensapandemien hausten 2009 i ein vestlandskommune.

BACKGROUND: In April 2009 the World Health Organization (WHO) declared that spreading of a new influenza A(H1N1) virus had reached epidemic proportions, and on June 11, 2009 they declared that the world was in fact facing a pandemic. In Norway the influenza pandemic was the cause of much activity from health authorities and all levels of the health services. This report concerns pandemic-related work within clinical and community medicine in a municipality in western Norway. MATERIAL AND METHODS: All contacts between the general practitioners (GPs) and patients with influenza-like disease in Austevoll municipality were recorded for the second half of 2009. The lead public health nurse recorded vaccination activity systematically. Absence from secondary school in the municipality was recorded and the Medical Health Officer recorded all pandemic-related activities. RESULTS: 141 patients living in the municipality (3.2 % of the population) contacted the GP for influenza-like disease. Most cases occurred during weeks 43-47. A large majority of the encounters with the GP during these weeks were with patients below 20 years of age, whereas the age distribution was much more diverse at other points in time. Absence from secondary school was also highest in weeks 43-47. 54 % of the municipality's inhabitants were vaccinated. At the end of the main wave of the epidemic, vaccination coverage had reached 28 %. The Medical Health Officer had a large workload, especially during the main wave. INTERPRETATION: The influenza epidemic in 2009 hit Austevoll municipality in weeks 43-47. Mass vaccination was started too late to have a major influence on the epidemic. Systematic mapping of the epidemic on a municipal level is a useful supplement to the national surveillance.

Hygiene campaign autumn 2009--fewer cases of infection at the emergency centre?

BACKGROUND: Prompted by the H1N1 influenza epidemic in autumn 2009, Norwegian health authorities launched a campaign for better hygiene. We wanted to investigate whether there was any change in the out-of-hours contact rate for infectious diseases during this campaign. MATERIAL AND METHODS: The material consisted of remuneration claims from all doctors doing out-of-hours work during the years 2006-2009. The contact rates for nine diagnoses of infectious illness in autumn 2009 were compared with a corresponding mean from the years 2006-2008. RESULTS: The contact rate for influenza was ten times higher in autumn 2009 than in the three preceding years. During the same period there was a significant reduction in conjunctivitis (contact rate ratio 0.74), otitis (0.73), sinusitis (0.70), throat infections (0.79), pneumonia (0.70) and intestinal infections (0.82). There were small changes in the contact rates for acute upper respiratory tract infections and urinary tract infections, but in December there was also a clear reduction in acute upper respiratory tract infections (0.61). INTERPRETATION: The reduced contact rates for infectious diseases may be ascribed to an effect of the campaign, but other factors may also have contributed to this result.

[Working style among regular general practitioners and other doctors in the out-of-hours services]. / Arbeidsstil hos fastleger og andre leger på legevakt.

BACKGROUND: RGPs (regular general practitioners) are obliged to take on duties in the out-of-hours services in Norway, but they actually perform less than half of this work. We wished to compare remuneration claims for out-of-hours work from RGPs with those from other doctors. MATERIAL AND METHODS: The Norwegian Labour and Welfare administration provided information about all doctors working in the out-of-hours services in Norway in 2006 (4 729 of whom 2 220 were RGPs) and coupled this with the remuneration they had claimed in this period. RESULTS: RGPs had 46.6 % of all patient contacts in the out-of-hours services, but more telephone contacts (57.4 %) and simple/short contacts (50.7 %) than other doctors. Other doctors had most contacts in the largest (59.8 %) and most central (56.7 %) municipalities and used general and unspecific diagnoses more often than the RGPs (12.6 % of all consultations vs. 11.0 %). Older doctors used fewer fees than younger doctors, but otherwise the total number of fees only differed slightly between various groups of doctors. Newly qualified doctors serving their compulsory practice period claimed extra remuneration for long consultations in 41.2 % of the cases, RGPs who are also general practice specialists in 20.2 % of cases, and other doctors in 35.7 % of the consultations. RGPs wrote sick notes more often (7.1 % of consultations) than newly qualified doctors (5.7 %) and other doctors (6.6 %). General practice specialists wrote sick notes most often (7.4 %). INTERPRETATION: Experienced RGPs and general practice specialists spend less time per patient than other doctors in the out-of-hours services.

[Out-of-hours medical services for retirement and nursing homes]. / Legevakt for alders- og sykehjemmene.

BACKGROUND: Effectivization of the Norwegian out-of-hours primary care medical services has probably rendered the services less available to residents in nursing homes in many places. In Bergen, an out-of-hours medical service especially dedicated to residents in retirement and nursing homes and people with special needs living at home, was established in March 2006. We wanted to assess this medical service after its first year of activity. MATERIAL AND METHODS: Data were prospectively recorded on when the services were used and characteristics of the users . Information about the institutions was also recorded. RESULTS: 926 patients used the services during the first year; more than half of them received sick calls. Pneumonias and urinary tract infections were the most common diagnoses. A high level of doctor staffing at the nursing homes did not lead to decreased use. Neither the total number of beds nor the number of short - time beds in the nursing homes had a significant influence on the use of this service. INTERPRETATION: This targeted out-of-hours service was used less than expected during its first year. The nursing homes' use of this service is determined by factors other than the number of beds and doctor staffing.

[Electronic emergency preparedness plans in Norwegian out-of-hours centres]. / Elektronisk kommunal beredskapsplan i legevaktsentral.

BACKGROUND: All Norwegian municipalities have prepared local emergency plans, but the usefulness of such plans has not been evaluated. The aim was to investigate how such an electronic plan is used in emergency situations in one of these municipalities (Askøy), with focus on quality work and the function of the local emergency medical communication centre(LEMC). MATERIAL AND METHODS: During 20 months all events that activated the emergency plan were registered and evaluated, either by evaluation meetings or otherwise. A structured questionnaire was sent to all participants in the local emergency services before and after the registrations. RESULTS: Ten emergency events were registered during the project period; 38 topics worked well, 52 topics had potential for improvement and 16 were deviations from the plan. Examples of evaluated topics are raising alarm and giving feedback within the services, use of nationwide radio communication system, on-site cooperation and use of the plan. In retrospect mapping of events showed that more situations could have led to activation of the plan. The questionnaire revealed that 70 % of respondents meant the cooperation was good or very good, both before and after the registrations. There were few changes in the answers before and after the project period. INTERPRETATION: An electronic emergency-preparedness plan used in emergency medical communication centres is a suitable tool in quality work and can be a valuable tool for evaluation of emergency situations.

[Cooperation between ambulance personnel and regular general practitioners]. / Samhandling mellom ambulansearbeider og legevaktlege.

BACKGROUND: The ambulance service in Norway has gone through a pronounced upgrading of skills and professionalization during the last 10 years. The purpose of this survey was to obtain knowledge on how the ambulance personnel perceive their own professional competence and their relationship to other occupational groups with whom they cooperate. MATERIAL AND METHOD: A questionnaire was sent to 300 persons who received authorization as ambulance personnel between 2002 - 2005. Questions were included on evaluation of inter-professional cooperation, professional appreciation and competence in practical handling of patients. RESULTS: The response rate was 52 %. The ambulance personnel regarded the most problematic relationships and situations to be with nurses and regular general practioners in the out-of-hours services and with doctors in connection with emergencies at accident sites. 78 % of the ambulance personnel claimed that their own occupational group has the highest competence in the practical handling of patients with acute illness and injuries outside of hospitals. Nevertheless, only 19 % of them felt that occupational groups with who they cooperate appreciate their competence. INTERPRETATION: Ambulance personnel have strong confidence in their own occupational group's competence in practical handling of patients. Strengthened formal competence combined with increased possibilities for initial medical treatment in the ambulances, may have contributed to an expanded role for ambulance personnel within pre-hospital emergency care. Smooth cooperation between regular general practitioners and ambulance personnel requires that both parties increase their understanding of the other group's procedures and roles.

[Equipment for diagnostics, laboratory analyses and treatment in out-of-hours services]. / Utstyr, laboratorieanalyser og medikamenter ved kommunale legevakter.

BACKGROUND: Availability of equipment for diagnostics and treatment in out-of-hours services in Norway is not documented and no guidelines exist on requirements for the various types of equipment (including drugs) needed. A knowledge basis on status and needs should be established so minimum requirements can be developed. MATERIAL AND METHODS: The National Centre for Emergency Primary Health Care sent a questionnaire on availability of diagnostic equipment, laboratory tests, medication and quality assurance systems to all 261 municipal out-of-hours services in Norway in February 2006. RESULTS: 223/261 (86 %) of the services responded. 150 used the same office as a day-time practice, 59 had their own office and 14 were localised in a hospital/ emergency care unit. Services located in GP surgeries with a daytime-practice had a wider range of equipment, laboratory tests and medicines. Physicians on duty in the out-of-hours services with shared facilities did much of the laboratory work, but the quality control was done by the personnel at daytime. 27 % of the independent services did not have external control of their laboratory work (they were not members of the Norwegian Quality Improvement of Primary Care Laboratories). GPs were trained on acute medical situations more than once a year in 52 % of all the out-of-hours-services, but for only 40 % in the independent services. Other personnel were trained more than once a year in 74 % of the independent services. INTERPRETATION: Availability of equipment and laboratory test repertoire for GPs on duty at out-of-hours services seems to depend on whether the services are shared with GP surgeries and also used at daytime, and the distance to ambulance, hospital and pharmacy. Lack of routines for laboratory work and low training frequency in acute medical procedures may lead to poor quality of the analyses and lower competence than needed.

[Development of events in medical emergency situations in a rural community]. / Akuttmedisinsk handsaming i ein utkantkommune.

BACKGROUND: A comprehensive study of medical emergency situations in a rural community in Norway has been undertaken for the first time. Some results from this study are presented; i.e. data on events (types and management) that occur in medical emergency situations. MATERIAL AND METHODS: Austevoll is an island community in western Norway, with about 4400 inhabitants. Data on all events in medical emergency situations were recorded during two years. The following information was recorded: degree of urgency at the time of the emergency call and at patient examination (as assessed by the doctor), treatment measures and the relationship between doctors' and ambulance personnel's assessments. RESULTS: 236 medical emergency events were recorded. The doctors downgraded the seriousness of the event (from emergency call to actual examination of the patient) in 43 % of cases, while the event was upgraded in 11 %. For alarms dispatched from the emergency medical communication centres, the doctors downgraded the evaluation of seriousness in the time span alarm-examination in 67 % of cases, while the ambulance personnel downgraded seriousness in 85 %. Home dwelling was the initial location of treatment in 63 % of patients. The procedures performed most frequently were: venous cannulation, airway handling (including administration of oxygen), ECG-recording and/or monitoring of cardiac rhythm, and parenteral administration of drugs. INTERPRETATION: For emergency medicine work general practitioners should focus on training fundamental practical skills. The doctors and the ambulance personnel have complementary roles in handling of medical emergency events. Ability of obtaining an adequate overall view of the patient's condition is an important aspect of the doctor's role.