The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study.

OBJECTIVE: Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor's list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors' services in collaborative parts of the health care system. DESIGN: An observational study. SETTING: Register-based retrospective quasi-experimental longitudinal follow-up study based on a before-after setting in a Finnish city. SUBJECTS: Patients who consulted different doctors in a local health care unit. MAIN OUTCOME MEASURES: Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage. RESULTS: The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased. CONCLUSIONS: The data suggested that the reverse triage causes redistribution of the use of doctors' services rather than a true decrease in the use of these services.

Altering a computerized laboratory test order form rationalizes ordering of laboratory tests in primary care physicians.

BACKGROUND: To reduce physicians' inappropriate laboratory requests for their patients, administrators have used methods such as modifying a laboratory request order form with an agreed requesting protocol for the most common diagnoses in primary health care. OBJECTIVE: To study the effects of removing the erythrocyte sedimentation rate (ESR) and aspartate transaminase (AST) which are considered of limited clinical value for primary care clinical decision-making from a computerized laboratory test order form. These tests were removed to another new view from the electronic laboratory menu where the physicians, instead of just ticking the desired test from the list, had to do 4-8s extra work by writing down the abbreviation to order the test. METHODS: An observational controlled prospective study based on a before-after design was performed by removing AST and ES from the laboratory test order form of the computerized laboratory system for all primary care in the city of Helsinki, Finland. The numbers of annual and monthly use of AST and ESR and their controls, alanine transaminase (ALT) and C-reactive protein (CRP) ordered by General practitioners (GPs) was recorded over an eight-year period: four years before and a four years after the removal of AST and ES. RESULTS: Removing AST and ESR from the computerized laboratory test order form decreased their use by up to 90%, whereas the use of the control tests increased throughout the follow-up period. The variation in use of these removed tests also decreased. CONCLUSION: Removing a laboratory test from a computerized laboratory test order form may significantly reduce GPs' use of the laboratory test. Further studies are needed, however, to ensure the safety of this type of intervention.