Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark.

BACKGROUND: Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS: We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS: Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION: The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.

Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study.

OBJECTIVE: To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates. DESIGN: Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data. SETTING: OOH primary care of the Central Denmark Region. SUBJECTS: All patient contacts in 2014-2017. MAIN OUTCOME MEASURES: GPs' tendency to prescribe antibiotics. Excess variation (not attributable to chance). RESULTS: We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including 'activity level' (i.e. number of patients seen in the past hour) for clinic and telephone consultations, 'familiarity with OOH care' (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r2: 0.008-0.025). CONCLUSION: Some variation in the GPs' tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs' activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners' activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.

Time trends in general practitioners' home visits for older patients: a retrospective cross-sectional study from Switzerland.

WHAT IS KNOWN ON THE SUBJECT, AND WHAT THE STUDY ADDS: The number of home visits by general practitioners (GPs) has decreased in recent years, in contrast to the increasing number of frail and older patients in western countries. Current data on GP home visit numbers and rates are lacking for Switzerland. Our study provides new data on GP home visit numbers and rates, and their associations with patient characteristics. AIM: Our study aimed at investigating the time trend of GP home visits to older patients from 2014 to 2018 in Switzerland, and associations between GP home visits and patient characteristics including healthcare utilisation and living situation. METHODS: Retrospective cross-sectional study of insurance claims data from 2014 to 2018 among patients aged ≥65 years (Nextrapolated = 2,095,102; Nraw = 339,301). We compared patient characteristics between patients with and without GP home visits using descriptive statistics. We performed logistic regression analyses to detect associations between patient characteristics and GP home visits, including subgroups of patients aged ≥80 and patients living in a nursing home. Regression models were adjusted for age and sex. RESULTS: The yearly GP home visit rate declined from 10.7% to 9.3% from 2014 to 2018 (p <0.0001). Among patients aged ≥80, the rate declined from 26.1% to 23.1% (p <0.0001), and among patients living in a nursing home from 68.7% to 65.8% (p <0.0001). Regression analyses revealed increased health care utilisation and a higher burden of morbidity and mortality in patients receiving GP home visits. CONCLUSION: There is an ongoing decline of GP home visits over the past years, with a potentially negative impact on the quality of care for older and frail patients.

Use of acute care services by adults with a migrant background: a secondary analysis of a EurOOHnet survey.

BACKGROUND: High demands create pressure on acute care services, such as emergency medical services (EMS), emergency departments (ED) and out-of-hours primary care (OOH-PC) services. A variety of patient- and organisational factors have been discussed as reasons why especially non-western migrants more frequently contact an ED or OOH-PC service than native born. We aim to investigate whether persons with a non-western and western migrant background more often contact an acute care service than native born and how this relates to the number of contacts with their general practitioners (GPs). In addition, we aim to explore how possible differences in acute care use by migrants can be explained. METHODS: We performed secondary analysis of data collected for the EurOOHnet survey on OOH help-seeking behaviour in Denmark, the Netherlands and Switzerland. Differences in self-reported acute care use (sum of number of contacts with OOH-PC, the ED and 1-1-2/1-4-4) between non-western and western migrants and native born were tested with a quasi Poisson regression analysis. Mediation analyses were performed to examine the impact of factors related to help-seeking on the relation between self-reported acute care use and migrant background. RESULTS: Non-western migrants had more acute care contacts than native born (adjusted IRR 1.74, 95% CI 1.33-2.25), whereas no differences were found between western migrants and native born. Migrants who regularly contacted OOH-PC or the ED also regularly contacted their GP. Mediation analyses showed that the factors employment, anxiety, attitude towards use of OOH-PC and problems in accessing the own GP could partly explain the higher acute care use of non-western migrants. CONCLUSION: The higher use of acute care services by non-western migrants compared with native born could partly be explained by feeling fewer barriers to contact these services, feeling more anxiety, more unemployment and problems making an appointment with the GP. Increasing awareness and improving GP access could help migrants in navigating the healthcare system.

Methodology of the DCCSS later fatigue study: a model to investigate chronic fatigue in long-term survivors of childhood cancer.

BACKGROUND: A debilitating late effect for childhood cancer survivors (CCS) is cancer-related fatigue (CRF). Little is known about the prevalence and risk factors of fatigue in this population. Here we describe the methodology of the Dutch Childhood Cancer Survivor Late Effect Study on fatigue (DCCSS LATER fatigue study). The aim of the DCCSS LATER fatigue study is to examine the prevalence of and factors associated with CRF, proposing a model which discerns predisposing, triggering, maintaining and moderating factors. Triggering factors are related to the cancer diagnosis and treatment during childhood and are thought to trigger fatigue symptoms. Maintaining factors are daily life- and psychosocial factors which may perpetuate fatigue once triggered. Moderating factors might influence the way fatigue symptoms express in individuals. Predisposing factors already existed before the diagnosis, such as genetic factors, and are thought to increase the vulnerability to develop fatigue. Methodology of the participant inclusion, data collection and planned analyses of the DCCSS LATER fatigue study are presented. RESULTS: Data of 1955 CCS and 455 siblings was collected. Analysis of the data is planned and we aim to start reporting the first results in 2022. CONCLUSION: The DCCSS LATER fatigue study will provide information on the epidemiology of CRF and investigate the role of a broad range of associated factors in CCS. Insight in associated factors for fatigue in survivors experiencing severe and persistent fatigue may help identify individuals at risk for developing CRF and may aid in the development of interventions.

Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials.

C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).

Indications and associated factors for prescribing intravenous iron supplementation in Swiss general practice: a retrospective observational study.

BACKGROUND: Intravenous iron supplementation (IVIS) is increasing in Swiss general practice. This is controversial because of higher costs and risks compared with oral iron supplementation (OIS). In this study, we aimed to investigate indications for OIS and IVIS in Swiss general practice and test which factors are associated with prescribing IVIS instead of OIS. METHODS: This was a retrospective observational study using data from electronic medical records of 279 Swiss general practitioners (GPs), including all their patients at their first OIS and IVIS administration who were at least 14 years old and with available pretreatment serum ferritin and haemoglobin measurements. We also collected data about the following comorbidities: chronic kidney disease (CKD) stage 3b or higher, inflammatory bowel disease (IBD), chronic heart failure and restless legs syndrome. Outcomes were proportions of cases treated with IVIS or OIS by assumed indication (anaemic or non-anaemic iron deficiency [NAID]) or the abovementioned comorbidities. We evaluated associations with IVIS prescription using regression models adjusting for patient and GP variables. RESULTS: We assessed 1282 IVIS and 3003 OIS cases (median age 44 and 40 years, female in 86.7 and 88.6%, respectively). The most important indication for both IVIS and OIS was NAID (59.4 and 74.7%, respectively). Significant associations with prescribing IVIS instead of OIS were the severity of iron deficiency (reflected by serum ferritin levels and the presence of anaemia), the presence of advanced CKD, IBD and male sex of the GP. There was a time trend towards increasing serum ferritin levels associated with initiation of IVIS in NAID. CONCLUSION: When preferring IVIS to OIS, Swiss GPs seem to consider severity of iron deficiency and comorbid conditions. However, pretreatment serum ferritin levels in IVIS for NAID are increasing, suggesting an ongoing indication extension and potential overuse.

Factors related to out-of-hours help-seeking for acute health problems: a survey study using case scenarios.

BACKGROUND: The acute out-of-hours healthcare services are challenged by increasing demand in many countries. We aimed to examine factors influencing the intended help-seeking in out-of-hours care for acute health problems during evenings, nights, and weekends. METHODS: We conducted a survey study based on data from parents of children (aged 0-4 years) and adults (aged 30-39 and 50-59 years) in Denmark, the Netherlands and Switzerland. Intended help-seeking behaviour was measured by six hypothetical case scenarios. We used Andersen's Behavioural Model to categorise potentially influential factors and applied multiple binomial regression to assess the influence of selected factors. RESULTS: A total of 1015 parents and 2942 adults participated. We identified several significant influential factors. Parents holding a low education (OR 1.56), having migrant background (western: OR 1.23; non-western: OR 1.93), having one child (OR 1.24), perceiving few barriers to using out-of-hours primary care (OR 1.59), perceiving difficulties with organising childcare (OR 1.13), and having a history of frequent contacts with out-of-hours care (OR 1.55) were more inclined to contact out-of-hours care, whereas female (OR 0.85) and non-anxious parents (OR 0.77) were less inclined. Adults who were older (OR 1.01), holding a medical education (OR 1.13), having non-western background (OR 1.28), being unemployed (OR 1.17), perceiving few barriers to using out-of-hours primary care (OR 1.37), and having a history of frequent contacts with a GP (few: OR 1.15; more: OR 1.22) and/or with out-of-hours care (one: OR 1.20; more: OR 1.49) were more inclined to contact out-of-hours care, whereas adults with no or little social support (OR 0.84) and adults with high health literacy level on health information (OR 0.91) were less inclined. Dutch parents were less inclined than Danish parents to contact out-of-hours care (OR 0.62), whereas Swiss adults were more inclined than Danish adults to contact out-of-hours care (OR 1.16). CONCLUSION: We identified several factors related to intended help-seeking in out-of-hours care. These results could be used to develop targeted interventions, but more research is needed to examine the underlying explanations for the identified differences.

Impact of alternative healthcare plans on out-of-hours help-seeking intentions in Switzerland.

INTRODUCTION: In Switzerland, mandatory health insurance plans (standard) offer free access to secondary and emergency care. However, in return for a lower premium, individuals can choose alternative healthcare plans (HCPs), with either a general practitioner (GP) or a medical call centre (Telmed) acting as gatekeeper. AIM: To examine the impact of alternative HCPs on patients' intended help-seeking behaviour out-of-hours (OOH) in Switzerland. METHODS: A secondary analysis of the Swiss data collected for the EurOOHnet survey on help-seeking behaviour in Denmark, the Netherlands and Switzerland was made. The survey used hypothetical scenarios for measuring two outcome measures: intended help-seeking for (1) OOH care and (2) OOH face-to-face care. Binomial regression analyses were used to test the influence of HCPs on intended OOH help-seeking, adjusted for other (population) characteristics. RESULTS: Telmed-insured persons were more inclined to OOH help-seeking than persons with a standard HCP (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.91-2.72; controlled for other population factors), mainly driven by contact with the medical call centre (31 vs 5%), and were less inclined to have an OOH face-to-face contact (OR 0.69, 95% CI 0.55-0.87). Persons with a GP HCP had a lower intended use of face-to-face OOH care contacts than persons with a standard plan (OR 0.74, 95% CI 0.63-0.86). CONCLUSION: Alternative HCPs on a voluntary basis seem to influence the use of OOH care. These results could be relevant for policy makers, especially from non-gatekeeping countries, to reduce irrelevant use and subsequent costs of emergency and OOH care services.

Help-seeking behaviour outside office hours in Denmark, the Netherlands and Switzerland: a questionnaire study exploring responses to hypothetical cases.

OBJECTIVES: We aim to study the preferred behaviour among individuals from different age groups in three countries when acute health problems occur outside office hours and thereby to explore variations in help-seeking behaviour. DESIGN: A questionnaire study exploring responses to six hypothetical cases describing situations with a potential need for seeking medical care and questions on background characteristics. SETTING: General population in Denmark, the Netherlands and Switzerland. POPULATION: Danish, Dutch and Swiss individuals from three age groups (0-4, 30-39, 50-59 years). MAIN OUTCOME MEASURES: Distribution of intended help-seeking preferences per case per age group, compared between countries. Differences in percentage of help-seeking outside office hours per age group and country, crude and adjusted for background characteristics. RESULTS: Danish and Dutch parents of children aged 0-4 years differed in intended help-seeking behaviour for five out of six cases (abdominal pain, red eyes, rash, relapse fever, chickenpox); Danish parents significantly more often chose to contact out-of-hours (OOH) care than Dutch parents. For adults aged 30-39 years, no significant difference between the three countries was found for contacting OOH care. Swiss adults aged 50-59 years had the highest percentage of OOH contacts (38.3%), followed by the Danish (33.4%) and the Dutch (32.5%). CONCLUSION: Some differences in help-seeking behaviour outside office hours exist between Danish, Dutch and Swiss individuals, particularly for parents of young children. The question remains whether these differences result from individual preferences, cultural disparities and/or health services variations. Future research should focus on identifying explanations for these differences to reduce undesirable use of OOH care.

[Migrants' motives and expectations for contacting out-of-hours primary care]. / Gebruik van de huisartsenpost door migranten.

BACKGROUND: Migrants relatively often use out-of-hours primary care. The objective of this study is to examine the motives and expectations of migrants for contacting out-of-hours primary care. METHODS: We used data from a survey study of 11,483 patients who contacted a General Practitioner (GP) cooperative in the Netherlands between 2009 and 2014 (response rate 45.6%). Logistic regression analysis was used to test differences in motives and expectations between non-western and western migrants and native Dutch patients. RESULTS: The most frequently mentioned motives and expectation of migrants to contact out-of-hours primary care were similar to Dutch patients. The main motives for respectively non-western and western migrants were an urgent need for a GP (54.9%/52.4%), worry (49.3%/43.0%), and a need for medical information (21.3%/26.2%). Compared to natives, non-western migrants more often perceived an urgent need for a GP (OR 1.65), less often needed information (OR 0.59), and like western migrants, more often experienced problems contacting their own GP during office hours (OR 1.71(non-western/1.38(western)). Most non-western and western migrants expected to see a doctor (46.2%/46.6%) or get advice (39.6%/41.5%). Non-western migrants expected more often to get physical examinations (OR 1.53), and prescriptions (OR 1.37). CONCLUSION: The main motives and expectations of migrants are similar to native Dutch patients, yet non-western migrants more often want action from the GP (e.g. examinations or prescriptions). At the same time, migrants experience problems accessing their own GP. We recommend education about the purpose of a GP cooperative, and examination and improvement of accessibility of daytime primary care.

Patient safety culture in out-of-hours primary care services in the Netherlands: a cross-sectional survey.

OBJECTIVE: To examine patient safety culture in Dutch out-of-hours primary care using the safety attitudes questionnaire (SAQ) which includes five factors: teamwork climate, safety climate, job satisfaction, perceptions of management and communication openness. DESIGN: Cross-sectional observational study using an anonymous web-survey. Setting Sixteen out-of-hours general practitioner (GP) cooperatives and two call centers in the Netherlands. Subjects Primary healthcare providers in out-of-hours services. Main outcome measures Mean scores on patient safety culture factors; association between patient safety culture and profession, gender, age, and working experience. RESULTS: Overall response rate was 43%. A total of 784 respondents were included; mainly GPs (N = 470) and triage nurses (N = 189). The healthcare providers were most positive about teamwork climate and job satisfaction, and less about communication openness and safety climate. The largest variation between clinics was found on safety climate; the lowest on teamwork climate. Triage nurses scored significantly higher than GPs on each of the five patient safety factors. Older healthcare providers scored significantly higher than younger on safety climate and perceptions of management. More working experience was positively related to higher teamwork climate and communication openness. Gender was not associated with any of the patient safety factors. CONCLUSIONS: Our study showed that healthcare providers perceive patient safety culture in Dutch GP cooperatives positively, but there are differences related to the respondents' profession, age and working experience. Recommendations for future studies are to examine reasons for these differences, to examine the effects of interventions to improve safety culture and to make international comparisons of safety culture. Key Points Creating a positive patient safety culture is assumed to be a prerequisite for quality and safety. We found that: • healthcare providers in Dutch GP cooperatives perceive patient safety culture positively; • triage nurses scored higher than GPs, and older and more experienced healthcare professionals scored higher than younger and less experienced professionals - on several patient safety culture factors; and • within the GP cooperatives, safety climate and openness of communication had the largest potential for improvement.

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care.

Background: Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service. Objective: The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service. Methods: We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient's own GP, using a questionnaire. Results: Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients' own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain. Conclusion: Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain.

Development and testing of the KERNset: an instrument to assess the quality of telephone triage in out-of-hours primary care services.

BACKGROUND: Telephone triage is a core but vulnerable part of the care process at out-of-hours general practitioner (GP) cooperatives. In the Netherlands, different instruments have been used for assessing the quality of telephone triage. These instruments focussed mainly on communicational aspects, and less on the medical quality of triage decisions. Our aim was to develop and test a minimum set of items to assess the quality of telephone triage. METHODS: A national survey among all GP cooperatives in the Netherlands was performed to examine the most important aspects of telephone triage. Next, corresponding items from existing instruments were searched on these topics. Subsequently, an expert panel judged these items on importance, completeness and formulation. The concept KERNset consisted of 24 items about the telephone conversation: 13 medical, ten communicational and one regarding both types. It was pilot tested on measurement characteristics, reliability, validity and variation between triagists. In this pilot study, 114 anonymous calls from four GP cooperatives spread across the Netherlands were judged by three out of eight raters, both internal and external raters. RESULTS: Cronbach's alpha was .94 for the medical items and .75 for the communicational items. Inter-rater reliability: complete agreement between the external raters was 45% and reasonable agreement 73% (difference of maximally one point on the five-point scale). Intra-rater reliability: complete agreement within raters was 55% and reasonable agreement 84%. There were hardly any differences between internal and external raters, but there were differences in strictness between individual raters. The construct validity was confirmed by the high correlation between the general impression of the call and the items of the KERNset. Of the differences within items 19% could be explained by differences between triage nurses, which means the KERNset is able to demonstrate differences between triage nurses. CONCLUSIONS: The KERNset can be used to assess the quality of telephone triage. The validity is good and differences between calls and between triage nurses can be measured. A more intensive training for raters could improve the reliability.

Migrants' motives and expectations for contacting out-of-hours primary care: a survey study.

BACKGROUND: Migrants are more likely to use out-of-hours primary care, especially for nonurgent problems. Their motives and expectations for help-seeking are as yet unknown. The objective of this study is to examine the motives and expectations of migrants for contacting out-of-hours primary care. METHODS: We used data from a survey study of 11,483 patients who contacted a General Practitioner (GP) cooperative in the Netherlands between 2009 and 2014 (response rate 45.6%). Logistic regression analysis was used to test differences in motives and expectations between non-western and western migrants and native Dutch patients. RESULTS: The main motives for contacting a GP cooperative for non-western and western migrants were an urgent need for contact with a GP (54.9%-52.4%), worry (49.3%-43.0%), and a need for medical information (21.3%-26.2%). These were also the most important motives for native Dutch patients. Compared to native Dutch patients, non-western migrants more often perceived an urgent need for a GP (OR 1.65; 99% CI 1.27-2.16), less often needed information (OR 0.59; 99% CI 0.43-0.81), and more often experienced problems contacting their own GP during office hours (OR 1.71; 99% CI 1.21-2.43). Western migrants also reported experiencing problems more often in contacting their own GP (OR 1.38; 99% CI 1.04-1.84). As well as for natives, most non-western and western migrants expected to see a doctor (46.2%-46.6%) or get advice (39.6%-41.5%). Non-western migrants expected more often to get physical examination (OR 1.53; 99% CI 1.14-2.04), and prescription (OR 1.37; 99% CI 1.00-1.88). We found no differences in expectations between western migrants and native Dutch patients. CONCLUSION: The main motives and expectations of migrants are similar to native Dutch patients, yet non-western migrants more often wanted action from the GP, e.g. examination or prescription, and less often passive forms of assistance such as giving information. At the same time they experience problems accessing their own GP. We recommend stimulation of self-care, education about the purpose of a GP cooperative, and examination and improvement of accessibility of daytime primary care.

The impact of demand management strategies on parents' decision-making for out-of-hours primary care: findings from a survey in The Netherlands.

OBJECTIVE: To explore the potential impact of demand management strategies on patient decision-making in medically non-urgent and urgent scenarios during out-of-hours for children between the ages of 0 and 4 years. DESIGN AND METHODS: We conducted a cross-sectional survey with paper-based case scenarios. A survey was sent to all 797 parents of children aged between 0 and 4 years from four Dutch general practitioner (GP) practices. Four demand management strategies (copayment, online advice, overview medical cost and GP appointment next morning) were incorporated in two medically non-urgent and two urgent case scenarios. Combining the case scenarios with the demand management strategies resulted in 16 cases (four scenarios each with four demand management strategies). Each parent randomly received a questionnaire with three different case scenarios with three different demand strategies and a baseline case scenario without a demand management strategy. RESULTS: The response rate was 47.4%. The strategy online advice led to more medically appropriate decision-making for both non-urgent case scenarios (OR 0.26; CI 0.11 to 0.58) and urgent case scenarios (OR 0.16; CI 0.08 to 0.32). Overview of medical cost (OR 0.59; CI 0.38 to 0.92) and a GP appointment planned the next morning (OR 0.57; CI 0.34 to 0.97) had some influence on patient decisions for urgent cases, but not for non-urgent cases. Copayment had no influence on patient decisions. CONCLUSION: Online advice has the highest potential to reduce medically unnecessary use. Furthermore it enhanced safety of parents' decisions on seeking help for their young children during out-of-hours primary care. Valid online information on health symptoms for patients should be promoted.

The Development and Performance of After-Hours Primary Care in the Netherlands: A Narrative Review.

In many Western countries, hospital emergency departments are overcrowded, leading to the desire to strengthen primary care, particularly after hours. To achieve this goal, an increasing number of Western nations are reorganizing their after-hours primary care systems into large-scale primary care physician (PCP) cooperatives. This article provides an overview of the organization, performance, and development of PCP cooperatives in the Netherlands. The Dutch after-hours primary care system might offer opportunities for other countries facing problems with after-hours care and inappropriate emergency department visits. During the past several years, the number of contacts with Dutch PCP cooperatives has increased to 245 contacts per 1000 citizens per year. Many contacts (45%) are nonurgent, and about half occur as part of a series of primary care contacts. Low accessibility and availability of daytime primary care are related to greater use of after-hours primary care. To prevent unnecessary attendance at the cooperatives, physicians advocate copayment, a stricter triage system, and a larger role for telephone doctors. More than half of the PCP cooperatives in the Netherlands have integrated with hospital emergency departments, forming "emergency care access points." This collaboration has decreased emergency department use by 13% to 22%, and treatment of self-referrals by PCP cooperatives in emergency care access points is safe and cost-effective. Direct access to diagnostic facilities may optimize efficiency even more. Other recent developments include access to electronic health records of daytime primary care practices, task substitution from physicians to nurses, and the launch of a 2-year training program for PCPs to become experts in emergency care.

The psychometric properties of the 'safety attitudes questionnaire' in out-of-hours primary care services in the Netherlands.

BACKGROUND: The Safety Attitudes Questionnaire (SAQ) is one of the most widely used instruments to assess safety culture among healthcare providers. The ambulatory version of the SAQ (SAQ-AV) can be used in the primary care setting. Our study objective was to examine the underlying factors and psychometric properties of the Dutch translation of the SAQ-AV in out-of-hours primary care services. DESIGN: Cross-sectional observational study using a web-survey. SETTING: Sixteen out-of-hours general practitioner cooperatives and two call centers in the Netherlands. PARTICIPANTS: Primary healthcare providers in out-of-hours services. MAIN OUTCOME MEASURES: Item-descriptive statistics, factor loadings, Cronbach's alpha scores, corrected item-total correlations, scale correlations. RESULTS: The questionnaire was answered by 853 (43.2%) healthcare professionals. In the factor analyses, 784 respondents were included; mainly general practitioners (N = 470) and triage nurses (N = 189). Items were included in the analyses based on question type and results from previous studies. Five factors were drawn with reliability scores between .49 and .86 and a good construct validity. The five factors covered 27 of the 62 questionnaire items, with three to five items per factor. CONCLUSIONS: The Dutch translation of the SAQ-AV, with five factors, seems to be a reliable tool for measuring patient safety culture and guide quality improvement interventions in out-of-hours primary care services. The Dutch factor structure differed from the original SAQ-AV and other translated versions. In future studies, the questionnaire should be validated further by examining if there is a relationship between the responses on the SAQ-AV, patient experiences, and the occurrence of adverse events.

Reducing the use of out-of-hours primary care services: A survey among Dutch general practitioners.

BACKGROUND: Out-of-hours primary care services have a high general practitioner (GP) workload with increasing costs, while half of all contacts are non-urgent. OBJECTIVES: To identify views of GPs to influence the use of the out-of-hours GP cooperatives. METHODS: Cross-sectional survey study among a random sample of 800 GPs in the Netherlands. RESULTS: Of the 428 respondents (53.5% response rate), 86.5% confirmed an increase in their workload and 91.8% felt that the number of patient contacts could be reduced. A total of 75.4% GP respondents reported that the 24-h service society was a 'very important' reason why patients with non-urgent problems attended the GP cooperative; the equivalent for worry or anxiety was 65.8%, and for easy accessibility, 60.1%. Many GPs (83.9%) believed that the way telephone triage is currently performed contributes to the high use of GP cooperatives. Measures that GPs believed were both desirable and effective in reducing the use of GP cooperatives included co-payment for patients, stricter triage, and a larger role for the telephone consultation doctor. GPs considered patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, as well as feedback concerning the use of GP cooperatives to practices and triage nurses also desirable, but less effective. CONCLUSION: This study provides several clues for influencing the use of GP cooperatives. Further research is needed to examine the impact and safety of these strategies. [Box: see text].

Contacts with out-of-hours primary care for nonurgent problems: patients' beliefs or deficiencies in healthcare?

BACKGROUND: In the Netherlands, about half of the patient contacts with a general practitioner (GP) cooperative are nonurgent from a medical perspective. A part of these problems can wait until office hours or can be managed by the patient himself without further professional care. However, from the patient's perspective, there may be a need to contact a physician immediately. Our objective was to determine whether contacts with out-of-hours primary care made by patients with nonurgent problems are the result of patients' beliefs or of deficiencies in the healthcare system. METHODS: We performed a survey among 2000 patients with nonurgent health problems in four GP cooperatives in the Netherlands. Two GPs independently judged the medical necessity of the contacts of all patients in this study. We examined characteristics, views and motives of patients with medically necessary contacts and those without medically necessary contacts. Descriptive statistics were used to describe the characteristics, views and reasons of the patients with medically unnecessary contacts and medically necessary contacts. Differences between these groups were tested with chi-square tests. RESULTS: The response rate was 32.3 % (N = 646). Of the nonurgent contacts 30.4 % were judged as medically necessary (95 % CI 27.0-34.2). Compared to patients with nonurgent but medically necessary contacts, patients with medically unnecessary contacts were younger and were more often frequent attenders. They had longer-existing problems, lower self-assessed urgency, and more often believed GP cooperatives are intended for all help requests. Worry was the most frequently mentioned motive for contacting a GP cooperative for patients with a medically unnecessary contact (45.3 %) and a perceived need to see a GP for patients with a medically necessary contact (44.2 %). Perceived availability (5.8 %) and accessibility (8.3 %) of a patient's own GP played a role for some patients. CONCLUSION: Motives for contacting a GP cooperative are mostly patient-related, but also deficiencies in access to general practice may partly explain medically unnecessary use. Efforts to change the use of GP cooperatives should focus on education of subgroups with an increased likelihood of contact for medically unnecessary problems. Improvement of access to daytime primary care may also decrease use of the GP cooperative.