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.

Prevalence and predictors of post-COVID-19 symptoms in general practice - a registry-based nationwide study.

BACKGROUND: With Norwegian national registry data, we assessed the prevalence of post-COVID-19 symptoms at least 3 months after confirmed infection, and whether sociodemographic factors and pre-pandemic health problems were risk factors for these symptoms. METHODS: All persons with a positive SARS-CoV-2 PCR test from February 2020 to February 2021 (exposed) were compared to a group without a positive test (unexposed) matched on age, sex, and country of origin. We used Cox regression to estimate hazard ratios (HR) for 18 outcome symptoms commonly described as post-COVID-19 related, registered by GPs. We compared relative risks (RR) for fatigue, memory disturbance, or shortness of breath among exposed and unexposed using Poisson regression models, assessing sex, age, education, country of origin, and pre-pandemic presence of the same symptom and comorbidity as possible risk factors, with additional analyses to assess hospitalisation for COVID-19 as a risk factor among exposed. RESULTS: The exposed group (N = 53 846) had a higher prevalence of most outcome symptoms compared to the unexposed (N = 485 757), with the highest risk for shortness of breath (HR 2.75; 95%CI 2.59-2.93), fatigue (2.08; 2.00-2.16) and memory disturbance (1.41;1.26-1.59). High HRs were also found for disturbance of smell/taste and hair loss, but frequencies were low. Concerning risk factors, sociodemographic factors were at large similarly associated with outcome symptoms in both groups. Registration of the outcome symptom before the pandemic increased the risk for fatigue, memory disturbance and shortness of breath after COVID-19, but these associations were weaker among exposed. Comorbidity was not associated with fatigue and shortness of breath in the COVID-19 group. For memory disturbance, the RR was slightly increased with the higher comorbidity score both among exposed and unexposed. CONCLUSION: COVID-19 was associated with a range of symptoms lasting more than three months after the infection.

The impact of variation in out-of-hours doctors' referral practices: a Norwegian registry-based observational study.

BACKGROUND: In a gatekeeping system, the individual doctor's referral practice is an important factor for hospital activity and patient safety. OBJECTIVE: The aim of the study was to investigate the variation in out-of-hours (OOH) doctors' referral practice, and to explore these variations' impact on admissions for selected diagnoses reflecting severity, and 30-day mortality. METHODS: National data from the doctors' claims database were linked with hospital data in the Norwegian Patient Registry. Based on the doctor's individual referral rate adjusted for local organizational factors, the doctors were sorted into quartiles of low-, medium-low-, medium-high-, and high-referral practice. The relative risk (RR) for all referrals and for selected discharge diagnoses was calculated using generalized linear models. RESULTS: The OOH doctors' mean referral rate was 110 referrals per 1,000 consultations. Patients seeing a doctor in the highest referring practice quartile had higher likelihood of being referred to hospital and diagnosed with the symptom of pain in throat and chest, abdominal pain, and dizziness compared with the medium-low quartile (RR 1.63, 1.49, and 1.95). For the critical conditions of acute myocardial infarction, acute appendicitis, pulmonary embolism, and stroke, we found a similar, but weaker, association (RR 1.38, 1.32, 1.24, and 1.19). The 30-day mortality among patients not referred did not differ between the quartiles. CONCLUSIONS: Doctors with high-referral practice referred more patients who were later discharged with all types of diagnoses, including serious and critical conditions. With low-referral practice, severe conditions might have been overlooked, although the 30-day mortality was not affected.

A major task for primary care doctors working out-of-hours (OOH) is to refer patients in need of acute specialized care to hospital. Acute referrals capture the major dilemma of not missing critically ill patients without overloading the hospital capacity. There is a known variation in referral practice between OOH doctors, and here we asked what impact this variation has for OOH patients. We divided OOH doctors in Norway into 4 groups according to their referral practice low, medium-low, medium-high, and high. Low had few referrals as a proportion of the total consultations, while the high group had many. If the patient saw a doctor in the high-referral group, there was an increased likelihood to be referred to hospital and given a symptom diagnosis, indicating that no severe disease was revealed. High-referral practice therefore may lead to more avoidable admissions. However, we also found the same but weaker effect for some critical conditions (heart infarction, acute appendicitis, pulmonary embolism, and stroke). Therefore, a low-referral practice may increase the risk of critical conditions being overlooked. These aspects of referral practice variation should be taken into consideration and call for strengthening the OOH framework for decision making regarding acute referrals.

Continuity of care and mortality for patients with chronic disease: an observational study using Norwegian registry data.

BACKGROUND: Research on continuity of care (CoC) is mainly conducted in primary care and has received little acknowledgment in other levels of care. This study sought to investigate CoC across care levels for patients with selected chronic diseases, along with its association with mortality. METHODS: In a registry-based cohort study, patients with ≥1 consultation in primary or specialist healthcare or hospital admission with asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, or heart failure in 2012 were linked to disease-related consultation data in 2013-2016. CoC was measured by Usual Provider of Care index (UPC) and Bice-Boxermann continuity of care score (COCI). Values equal to one were categorized into one group and the rest into three equal groups (tertiles). The association with mortality was determined by Cox regression models. RESULTS: The highest mean UPCtotal was measured for patients with diabetes mellitus (0.58) and the lowest for those with asthma (0.46). The population with heart failure had the highest death rate (26.5). In adjusted Cox regression analyses for COPD, mortality was 2.6 times higher (95% CI 2.25-3.04) for patients in the lowest tertile of continuity compared to those with UPCtotal = 1. Patients with diabetes mellitus and heart failure showed similar results. CONCLUSION: CoC was moderate to high for disease-related contacts across care levels. A higher mortality associated with lower CoC was observed for patients with COPD, diabetes mellitus, and heart failure. A similar, but not statistically significant trend was found for patients with asthma. This study suggests that higher CoC across levels of care can decrease mortality.

Young adults with depression: A registry-based longitudinal study of work-life marginalisation. The Norwegian GP-DEP study.

AIMS: To explore the association between a depression diagnosis in young adulthood and risk of marginalisation at age 29 years, among those who had completed upper secondary school and those who had not completed at age 21. METHODS: In a longitudinal cohort study based on nationwide registers we followed 111,558 people from age 22-29 years. Outcomes were risk of marginalisation and educational achievement at age 29. Exposure was a diagnosed depression at ages 22-26 years. Comorbid mental and somatic health conditions, gender and country of origin were covariates. Relative risks were estimated with Poisson regression models, stratified by educational level at age 21. RESULTS: For people who had not completed upper secondary school at age 21 years, a depression diagnosis at age 22-26 increased the risk of low income (relative risk = 1.33; 95% confidence interval = 1.25-1.40), prolonged unemployment benefit (1.46; 1.38-1.55) and social security benefit (1.56; 1.41-1.74) at age 29 compared with those with no depression. Among those who had completed upper secondary school at age 21 years, depression increased the risk of low income (1.71; 1.60-1.83), prolonged unemployment benefit (2.17; 2.03-2.31), social security benefit (3.62; 2.91-4.51) and disability pension (4.43; 3.26-6.01) compared with those with no depression. Mental comorbidity had a significant impact on risk of marginalisation in both groups. CONCLUSIONS: Depression in one's mid-20s significantly increases the risk of marginalisation at age 29 years, and comorbid mental health conditions reinforce this association. Functional ability should be given priority in depression care in early adulthood to counteract marginalisation.

Lower levels of physical activity volume are beneficial, and it's never too late to start: Results from the HUNT Study, Norway.

AIMS: We aimed to explore (a) how different patterns of physical activity (PA) over time (36 years) were associated with all-cause and cause-specific mortality, (b) if the association was similar for males and females and for different body mass levels and (c) how change in PA was associated with mortality for subjects who started out as physically inactive. METHODS: The study is based on the prospective population-based cohort Trøndelag Health Study (HUNT) from 1984 to 2020, across four study waves. Data were linked to the Norwegian Cause of Death Registry. There were 123,005 participants, divided into three groups: persistently active, persistently inactive and mixed, with two cut-offs for PA: 60 and 150 minutes per week. The results are reported as cumulative incidence and hazard ratios (HRs). RESULTS: At 60 minutes of PA per week, 8% of participants were persistently inactive, 15% were persistently active and 77% had a mixed pattern. At 150 minutes, the corresponding numbers were 32%, 2% and 65%. Compared to the persistently inactive group, for the 60-minute cut-off, the mixed group had an all-cause mortality HR of 0.83 (95% confidence interval (CI) 0.70-0.98), and the persistently active group had an HR of 0.51 (95% CI 0.40-0.65). For the 150-minute cut-off, the corresponding HRs were 0.84 (95% CI 0.75-0.94) and 0.48 (95% CI 0.26-0.88). The patterns were similar for males and females and across body mass index levels. Initially inactive participants had lower mortality if they ended up physically active, regardless of their activity level at an intermediate time point. CONCLUSIONS: At least 60 minutes of PA per week was associated with a marked reduction in mortality when this was a lasting habit over three decades. Given that six times as many people reach this less ambitious goal, it is vital to encourage all levels of PA in public health promotion. Any increase in PA during the lifespan is beneficial.

Continuity of care for patients with chronic disease: a registry-based observational study from Norway.

BACKGROUND: Continuity of care (CoC) is accepted as a core value of primary care and is especially appreciated by patients with chronic conditions. Nevertheless, there are few studies investigating CoC for these patients across levels of healthcare. OBJECTIVE: This study aims to investigate CoC for patients with somatic chronic diseases, both with regular general practitioners (RGPs) and across care levels. METHODS: We conducted a registry-based observational study by using nationwide consultation data from Norwegian general practices, out-of-hours services, hospital outpatient care, and private specialists with public contracts. Patients with diabetes mellitus (type I or II), asthma, chronic obstructive pulmonary disease, or heart failure in 2012, who had ≥2 consultations with these diagnoses during 2014 were included. CoC was measured during 2014 by using the usual provider of care (UPC) index and Bice-Boxerman continuity of care score (COCI). Both indices have a value between 0 and 1. RESULTS: Patients with diabetes mellitus comprised the largest study population (N = 79,165) and heart failure the smallest (N = 4,122). The highest mean UPC and COCI were measured for patients with heart failure, 0.75 and 0.77, respectively. UPC increased gradually with age for all diagnoses, while COCI showed this trend only for asthma. Both indices had higher values in urban areas. CONCLUSIONS: Our findings suggest that CoC in Norwegian healthcare system is achieved for a majority of patients with chronic diseases. Patients with heart failure had the highest continuity with their RGP. Higher CoC was associated with older age and living in urban areas.

The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage.

BACKGROUND: Patients referred to specialised mental health care are usually triaged based on referral information provided by general practitioners. However, knowledge about this system's ability to ensure timely access to and equity in specialised mental health care is limited. We aimed to investigate to the degree to which patient triage, based on referral letter information, corresponds to triage based on a hospital specialist's consultation with the patient, and whether the degree of correspondence is affected by the quality of the referral letter. METHODS: We gathered information from three specialised mental health centres in Norway regarding patients that were referred and offered health care (N = 264). Data consisted of triage decisions for each patient (i.e., the hospital specialist's assessment of maximum acceptable waiting time), which were determined on the basis of a) referral information and b) meeting the patient. Referral letter quality was evaluated using the Quality of Referral information-Mental Health checklist. The reliability of priority setting and the impact of referral letter quality on this measure were investigated using descriptive analyses, binary logistic regression and Nadaraya-Watson kernel regression. RESULTS: In 143 (54%) cases, the triage decision based on referral information corresponded with the decision based on patient consultation. In 70 (27%) cases, the urgency of need for treatment was underestimated when based on referral information compared with that based on information from patient consultation. Referral letter quality could not explain the differences between the two triage decisions. However, when a cut-off value of 7 on the Quality of Referral information-Mental Health scale was used, low-quality letters were found more frequently among patients whose urgency of need was underestimated, compared with those whose need was overestimated. CONCLUSIONS: Deciding the urgency of patient need for specialised mental health care based on referral information is a reliable system in many situations. However, the possibility of under- and overestimation is present, implying risks to patient safety and inappropriate use of resources. Improving the content of referral letters does not appear to reduce this risk when the letters are of acceptable quality. TRIAL REGISTRATION: NCT01374035 .

Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study.

BACKGROUND: General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient's gender, age, and GP or OOH doctor referral. METHODS: A registry-based study was performed by linking national data from primary care in the physicians' claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR. RESULTS: Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men. CONCLUSIONS: The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.

Practice characteristics influencing variation in provision of depression care in general practice in Norway; a registry-based cohort study (The Norwegian GP-DEP study).

BACKGROUND: There is growing evidence of variation in treatment for patients with depression, not only across patient characteristics, but also with respect to the organizational and structural framework of general practitioners' (GPs') practice. However, the reasons for these variations are sparsely examined. This study aimed to investigate associations of practice characteristics with provision of depression care in general practices in Norway. METHODS: A nationwide cohort study of residents aged ≥ 18 years with a new depression episode in general practice during 2009-2015, based on linked registry data. Exposures were characteristics of GP practice: geographical location, practice list size, and duration of GP-patient relationship. Outcomes were talking therapy, antidepressant medication and sick listing provided by GP during 12 months from date of diagnosis. Associations between exposure and outcome were estimated using generalized linear models, adjusted for patients' age, gender, education and immigrant status, and characteristics of GP practice. RESULTS: The study population comprised 285 113 patients, mean age 43.5 years, 61.6% women. They were registered with 5 574 GPs. Of the patients, 52.5% received talking therapy, 34.1% antidepressant drugs and 54.1% were sick listed, while 17.3% received none of the above treatments. Patients in rural practices were less likely to receive talking therapy (adjusted relative risk (adj RR) = 0.68; 95% confidence interval (CI) = 0.64-0.73) and more likely to receive antidepressants (adj RR = 1.09; 95% CI = 1.04-1.14) compared to those in urban practices. Patients on short practice lists were more likely to receive medication (adj RR = 1.08; 95% CI = 1.05-1.12) than those on long practice lists. Patients with short GP-patient relationship were more likely to receive talking therapy (adj RR = 1.20; 95% CI = 1.17-1.23) and medication (adj RR = 1.08; 95% CI = 1.04-1.12), and less likely to be sick-listed (RR = 0.88; 95% CI = 0.87-0.89), than patients with long GP-patient relationship. CONCLUSIONS: Provision of GP depression care varied with practice characteristics. Talking therapy was less commonly provided in rural practices and among those with long-lasting GP-patient relationship. These differences may indicate some variation, and therefore, its reasons and clinical consequences need further investigation.

Comparison of depression care provided in general practice in Norway and the Netherlands: registry-based cohort study (The Norwegian GP-DEP study).

BACKGROUND: Depression is highly prevalent in general practice, and organisation of primary health care probably affects the provision of depression care. General practitioners (GPs) in Norway and the Netherlands fulfil comparable roles. However, primary care teams with a mental health nurse (MHN) supplementing the GP have been established in the Netherlands, but not yet in Norway. In order to explore how the organisation of primary mental care affects care delivery, we aimed to examine the provision of GP depression care across the two countries. METHODS: Registry-based cohort study comprising new depression episodes in patients aged ≥ 18 years, 2011-2015. The Norwegian sample was drawn from the entire population (national health registries); 297,409 episodes. A representative Dutch sample (Nivel Primary Care Database) was included; 27,362 episodes. Outcomes were follow-up consultation(s) with GP, with GP and/or MHN, and antidepressant prescriptions during 12 months from the start of the depression episode. Differences between countries were estimated using negative binomial and Cox regression models, adjusted for patient gender, age and comorbidity. RESULTS: Patients in the Netherlands compared to Norway were less likely to receive GP follow-up consultations, IRR (incidence rate ratio) = 0.73 (95% confidence interval (CI) 0.71-0.74). Differences were greatest among patients aged 18-39 years (adj IRR = 0.64, 0.63-0.66) and 40-59 years (adj IRR = 0.71, 0.69-0.73). When comparing follow-up consultations in GP practices, including MHN consultations in the Netherlands, no cross-national differences were found (IRR = 1.00, 0.98-1.01). But in age-stratified analyses, Dutch patients 60 years and older were more likely to be followed up than their Norwegian counterparts (adj IRR = 1.21, 1.16-1.26). Patients in the Netherlands compared to Norway were more likely to receive antidepressant drugs, adj HR (hazard ratio) = 1.32 (1.30-1.34). CONCLUSIONS: The observed differences indicate that the organisation of primary mental health care affects the provision of follow-up consultations in Norway and the Netherlands. Clinical studies are needed to explore the impact of team-based care and GP-based care on the quality of depression care and patient outcomes.

Construction and validation of a morbidity index based on the International Classification of Primary Care.

OBJECTIVES: In epidemiological studies it is often necessary to describe morbidity. The aim of the present study is to construct and validate a morbidity index based on the International Classification of Primary Care (ICPC-2). DESIGN AND SETTING: This is a cohort study based on linked data from national registries. An ICPC morbidity index was constructed based on a list of longstanding health problems in earlier published Scottish data from general practice and adapted to diagnostic ICPC-2 codes recorded in Norwegian general practice 2015 - 2017. SUBJECTS: The index was constructed among Norwegian born people only (N = 4 509 382) and validated in a different population, foreign-born people living in Norway (N = 959 496). MAIN OUTCOME MEASURES: Predictive ability for death in 2018 in these populations was compared with the Charlson index. Multiple logistic regression was used to identify morbidities with the highest odds ratios (OR) for death and predictive ability for different combinations of morbidities was estimated by the area under receiver operating characteristic curves (AUC). RESULTS: An index based on 18 morbidities was found to be optimal, predicting mortality with an AUC of 0.78, slightly better than the Charlson index (AUC 0.77). External validation in a foreign-born population yielded an AUC of 0.76 for the ICPC morbidity index and 0.77 for the Charlson index. CONCLUSIONS: The ICPC morbidity index performs equal to the Charlson index and can be recommended for use in data materials collected in primary health care.Key pointsThis is the first morbidity index based on the International Classification of Primary Care, 2nd edition (ICPC-2)It predicted mortality equal to the Charlson index and validated acceptably in a different populationThe ICPC morbidity index can be used as an adjustment variable in epidemiological research in primary care databases.

Patient experiences with depression care in general practice: a qualitative questionnaire study.

OBJECTIVE: To investigate patient experiences and preferences regarding depression care in general practice. DESIGN AND SETTING: A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis. SUBJECTS: 250 persons completed the web-based survey, 86% were women. RESULTS: The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful. CONCLUSIONS: Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment.KEY POINTSDepression is common, and GPs are often patients' first point of contact when they seek help. • Patients who feel depressed appreciate help from their GP. • Patients prefer an empathetic GP who listens attentively and acknowledges their problems. • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.

Variation in general practitioners' depression care following certification of sickness absence: a registry-based cohort study.

BACKGROUND: Depression is more prevalent among women and people with low socio-economic status. Uncertainties exist about how general practitioner (GP) depression care varies with patients' social position. OBJECTIVE: To investigate associations between patients' gender and educational status combined and GP depression care following certification of sickness absence. METHODS: Nationwide registry-based cohort study, Norway, 2012-14. Reimbursement claims data from all consultations in general practice for depression were linked with information on socio-demographic data, social security benefits and depression medication. The study population comprised all individuals aged 25-66 years with taxable income, sick-listed with a new depression diagnosis in general practice in 2013 (n = 8857). We defined six intersectional groups by combining educational level and gender. The outcome was type of GP depression care during sick leave: follow-up consultation(s), talking therapy, medication and referral to secondary care. Associations between intersectional groups and outcome were estimated using generalized linear models. RESULTS: Among long-term absentees (17 days or more), highly educated women were less likely to receive medication compared to all other patient groups [relative risk (RR) ranging from 1.17 (95% confidence interval 1.03-1.33) to 1.49 (1.29-1.72)] and more likely to receive talking therapy than women with medium [RR = 0.90 (0.84-0.98)] or low [RR = 0.91 (0.85-0.98)] education. CONCLUSIONS: Our findings suggest that GPs provide equitable depression care regarding consultations and referrals for all intersectional groups but differential drug treatment and talking therapy for highly educated women. GPs need to be aware of these variations to provide personalized care and to prevent reproducing inequity.

Trends in treatment for patients with depression in general practice in Norway, 2009-2015: nationwide registry-based cohort study (The Norwegian GP-DEP Study).

BACKGROUND: Depression is highly prevalent, but knowledge is scarce as to whether increased public awareness and strengthened government focus on mental health have changed how general practitioners (GPs) help their depressed patients. This study aimed to examine national time trends in GP depression care and whether trends varied regarding patient gender, age, and comorbidity. METHODS: Nationwide registry-based cohort study, Norway. The study population comprised all residents aged 20 years or older with new depression diagnoses recorded in general practice, 2009-2015. We linked reimbursement claims data from all consultations in general practice for depression with information on demographics and antidepressant medication. The outcome was type(s) of GP depression care during 12 months from the date of diagnosis: (long) consultation, talking therapy, antidepressant drug treatment, sickness absence certification, and referral to secondary mental health care. Covariates were patient gender, age, and comorbidity. The data are presented as frequencies and tested with generalized linear models. RESULTS: We included 365,947 new depression diagnoses. Mean patient age was 44 years (SD = 16), 61.9 % were women, 41.2 % had comorbidity. From 2009 to 2015, proportions of patients receiving talking therapy (42.3-63.4 %), long consultations (56.4-71.8 %), and referral to secondary care (16.6-21.6 %) increased, while those receiving drug treatment (31.3-25.9 %) and sick-listing (58.1-50 %) decreased. The trends were different for gender (women had a greater increase in talking therapy and a smaller decrease in sick-listing, compared to men), age (working-aged patients had a smaller increase in talking therapy, a greater increase in long consultations, and a smaller decrease in antidepressant drug use, compared to older patients) and comorbidity (patients with mental comorbidity had a smaller increase in talking therapy and a greater increase in long consultations, compared to those with no comorbidity and somatic comorbidity). CONCLUSIONS: The observed time trends in GP depression care towards increased provision of psychological treatment and less drug treatment and sick-listing were in the desired direction according to Norwegian health care policy. However, the large and persistent differences in treatment rates between working-aged and older patients needs further investigation.

Correction to: General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study.

An amendment to this paper has been published and can be accessed via the original article.

The effect of team collaboration and continuity of care on health and disability among rehabilitation patients: a longitudinal survey-based study from western Norway.

PURPOSE: The purpose of this study was to investigate how changes in patient-rated health and disability from baseline to after rehabilitation were associated with communication and relationships in rehabilitation teams and patient-rated continuity of care. METHODS: Linear models were used to assess the associations between relational coordination [RC] and Nijmegen Continuity Questionnaire-Norwegian version [NCQ-N] with changes in the World Health Association Disability Assessment Schedule 2.0 [WHODAS 2.0] and EuroQol EQ-VAS [EQ-VAS]. To express change in WHODAS 2.0 and EQ-VAS, the model was adjusted for WHODAS 2.0 and EQ-VAS baseline scores. Analyses for possible slopes for the various diagnosis groups were performed. RESULTS: A sample of 701 patients were included in the patient cohort, followed from before rehabilitation to 1 year after a rehabilitation stay involving treatment by 15 different interprofessional teams. The analyses revealed associations between continuity of care and changes in patient-rated health, measured with EQ-VAS (all p values < 0.01). RC communication was associated with more improvement in functioning in neoplasms patient group, compared to improvement of health among included patient groups. The results revealed no associations between NCQ-N and WHODAS 2.0 global score, or between RC in the rehabilitation teams treating the patients and changes in WHODAS 2.0 global score. CONCLUSION: The current results revealed that better personal, team and cross-boundary continuity of rehabilitation care was associated with better patient health after rehabilitation at 1-year follow-up. Measures of patient experiences with different types of continuity of care may provide a promising indicator of the quality of rehabilitation care.

Adolescents consulting general practitioners for psychological problems-a nationwide, register-based study in Norway.

Background: Psychological problems are increasing among adolescents, but little is known about the role of GPs in this area. Objectives: This study aims to investigate the frequency of GP consultations with a psychological diagnosis in adolescence and predictors for such help seeking. Methods: Nationwide longitudinal register-based study investigating GP consultations among adolescents aged 13-17 years (N = 123 516) in Norway. First, all GP consultations within the study population were identified from the national GP claims register for 2006-11. Second, adolescents with a first-time consultation with a psychological diagnosis at age 15-16 years were identified, and prior GP consultations, prior somatic diagnoses, parental education and GP and GP-practice characteristics were assessed as possible predictors for seeking help. Results: From age 13 to 17 years, 15.3% of girls and 13.0% of boys had ≥1 GP consultation with a psychological diagnosis. In total, 6.8% of girls and 4.8% of boys consulted a GP for the first time with a psychological problem at age 15-16 years. For both sexes, number of prior GP consultations and a prior diagnosis of headache and abdominal pain predicted consulting with an internalizing problem (depression, anxiety and stress). A prior headache diagnosis predicted consulting for behavioural problems. Psychological diagnoses were more often found among adolescents with lower parental education. There were only minor associations with GP characteristics. Conclusions: Norwegian adolescents often consult a GP and one in seven had a GP-diagnosed psychological problem at age 13-17. Policies to improve mental health care for adolescents should include strengthening of GP services.

Patient-reported depression treatment and future treatment preferences: an observational study in general practice.

BACKGROUND: Depression is prevalent in general practice, but few studies have explored patient-reported depression care. AIM: To investigate patient-reported treatment received for depression and future treatment preferences among adult patients visiting their GP, and to evaluate the associations with sex, age and educational level. DESIGN AND SETTING: A cross-sectional survey was conducted in general practices in Norway from 2016 to 2017. METHODS: Altogether, 2335 consecutive patients (response rate, 89.2%) in the GPs' waiting rooms answered a questionnaire about their received depression treatment and treatment preferences in case of future depression. RESULTS: The study population (N = 2239) had a mean age of 48.6 ± 17.7 years (range 18-91), 60.1% were women. Of the 770 patients reporting to have received depression treatment, 39.1% were treated exclusively by their GP while 52.5% also were referred to a psychologist/psychiatrist. Older age was positively associated with medication and negatively associated with referrals to psychologist/psychiatrist. People with high education had lower odds for receiving medication (odds ratios [OR], 0.49; 95% confidence intervals [CI]: 0.30-0.80) compared to those with low education. If future depression, 81.6% of the respondents would discuss this with their GP, 60.9% would prefer talking therapy with their GP, 22.5% medication, and 52.9% referral to psychologist or psychiatrist. CONCLUSION: One-third of the patients attending their GPs had consulted with them at some time concerning depression the case of future depression, most patients preferred talking therapy with the GP. This finding warrants increased research focus on the GP's role in depression care.

Adolescent self-rated health predicts general practice attendance in adulthood: Results from the Young-HUNT1 survey.

AIMS: Self-rated health (SRH) is a predictor of future health. However, the association between SRH in adolescence and health problems and health care utilization in adulthood has rarely been investigated. The aim of this study was to examine adolescent SRH as a predictor of general practitioner consultations in adulthood. METHODS: SRH was registered in the Young-HUNT1 survey in 1995-1997 ( N=8828, mean age 16 years, 88% participation rate). General practitioner consultations during 2006-2014 were obtained from a national claims database. The predictive value of adolescent SRH on general practitioner consultations in adulthood was analysed by regression models estimating the relative risks (RR) for the total number of consultations and consultations for psychological, gastrointestinal, musculoskeletal or respiratory problems. Age, sex and baseline measures of chronic disease and health care attendance were used as the adjusting variables. RESULTS: SRH was reported as 'very good' by 28.4%, 'good' by 60.6% and 'not good' by 11.0% of the respondents. The increases in consultation rates were 21% (RR 1.21, 95% CI 1.15-1.27) and 52% (RR 1.52, 95% CI 1.40-1.64) when comparing respondents with 'very good' SRH to those with 'good' and 'not good' SRH, respectively. We also demonstrated a dose-response association between adolescent SRH and general practitioner consultations for psychological, gastrointestinal, musculoskeletal or respiratory problems. CONCLUSIONS: SRH in adolescence is a predictor for general practitioner consultations in adult life. Previous research shows that SRH is influenced by factors such as well-being, health behaviour, functional status and body satisfaction. Intervention studies are needed to evaluate whether population-based and clinical interventions can improve SRH by improving these factors among adolescents.