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.

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.

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.

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.

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway.

BACKGROUND: Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere. AIM: To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality. DESIGN AND SETTING: Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs. METHOD: Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses. RESULTS: Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years. CONCLUSION: Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.

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.

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.

Children with otitis attending emergency primary health care units following introduction of pneumococcal vaccine. / Barn på legevakt med ørebetennelse etter innføring av pneumokokkvaksinen.

BACKGROUND: Otitis is a frequently occurring condition in young children and involves considerable use of antibiotics. The most common bacterial cause is pneumococci. The pneumococcal vaccine was introduced as part of the Childhood Immunisation Programme in Norway in 2006. The purpose of the study was to investigate whether this vaccination may have reduced the number of otitis cases presenting at emergency primary health care units. MATERIAL AND METHOD: The material consists of data from all electronic reimbursement claims from emergency primary health care doctors in the period 2006-18. Annual consultation rates were calculated for children aged 0-5 years attending an emergency primary health care unit, both in total and due to otitis. Registration of vaccination coverage in this age group began in 2006. RESULTS: The total consultation rate fell from 674 per 1000 inhabitants in 2006 to 502 in 2018 (a relative reduction of 26 %). The consultation rate for otitis fell from 44 per 1000 inhabitants to 21 (a relative reduction of 52 %). While the total rate fell steadily throughout the period, the reduction in consultation rates for otitis began to fall in 2011, when vaccination coverage in this group was over 90 %. INTERPRETATION: The pneumococcal vaccine may have reduced the number of children presenting with otitis at an emergency primary health care unit.

Children with gastroenteritis attending emergency primary healthcare units before and after the introduction of the rotavirus vaccine. / Barn på legevakt med gastroenteritt før og etter innføring av rotavirusvaksinen.

BACKGROUND: The rotavirus is the most frequent cause of severe diarrhoea in small children. The purpose of this study was to map emergency primary health care consultations due to gastroenteritis in small children before and after the introduction of the rotavirus vaccine on 1 October 2014. MATERIAL AND METHOD: The material consists of data from all electronic reimbursement claims from emergency primary health care doctors in the period 2010-18. Quarterly consultation rates at the emergency primary health care units for children aged 0-4 years with gastroenteritis were calculated. The consultation rate ratio for the years 2015-18 was calculated by dividing the consultation rate by the corresponding mean for the years 2010-13. RESULTS: The consultation rate was highest in the first quarter of the year. In the years 2010-13 (prior to the introduction of the vaccine), infants had a mean consultation rate of 9.7 per 1000 inhabitants, one-year-olds 14.3 and two-year-olds 7.3. In 2016 (after the introduction of the vaccine), the consultation rate ratio in the first quarter was 0.5 for infants, 0.3 for one-year-olds and 0.4 for two-year-olds. In 2017 and 2018, the corresponding consultation rate ratio was 0.5 for infants, 0.4 for one-year-olds and 0.5 for two-year-olds. Three-year-olds and four-year-olds had lower consultation rates and fewer changes over time. INTERPRETATION: The strong decline in gastroenteritis-related consultation rates may be related to the introduction of the rotavirus vaccine as part of the Childhood Immunisation Programme.

General practitioners' provision of end-of-life care and associations with dying at home: a registry-based longitudinal study.

BACKGROUND: General practitioners (GPs) may play an important role in providing end-of-life care to community-dwelling people. OBJECTIVE: To investigate patients' contacts with GPs, GPs' interdisciplinary collaboration, out-of-hours services and hospitalizations in the last 13 weeks of life and associations with dying at home. Second, investigate whether GP contacts were associated with fewer out-of-hours contacts or days hospitalized. METHODS: Individually linked data from the Norwegian Cause of Death Registry, Norwegian Patient Registry, Statistics Norway and Control and Payment of Reimbursement to Health Service Providers database for all 80 813 deceased people in Norway within 2012-13. Outcomes were analyzed with logistic regression and negative binomial multilevel mixed-effect models. RESULTS: Overall, 1% of people received GP home visits in Week 13 and 4.6% in the last week before death. During the last 4 weeks of life, 9.2% received one or more GP home visits. Altogether, 6.6% received one or more home visits when the GP had one or more interdisciplinary collaborations during the last 4 weeks, of which <3% died at home. GP office consultations decreased towards the end of life. The likelihood of home death versus another location increased in relation to GP home visits [one home visit odds ratio (OR) 1.92, confidence interval (CI) 1.71-2.15; two or more OR 3.49, CI 3.08-3.96] and GP interdisciplinary collaboration (one contact OR 1.76, CI 1.59-1.96; two or more OR 2.52, CI 2.32-2.74). CONCLUSIONS: GPs play a role in enabling people to die at home by performing home visits and collaborating with other health care personnel. Only a minority received such services in Norway.

Emergency primary health care consultations on Christmas Eve, New Year's Eve and a normal Saturday. / Legevaktkonsultasjoner julaften, nyttårsaften og en vanlig lørdag.

BACKGROUND: The objective was to compare the use of emergency primary health care services on Christmas Eve and New Year's Eve to a normal Saturday. MATERIAL AND METHOD: The material comprises data obtained from reimbursement claims from all doctors on out-of-hours duty in Norway in the period 2008-18. The number of consultations and home visits, and the diagnoses set, were recorded for Christmas Eve, New Year's Eve and the last Saturday of January. Comparisons were differentiated between daytime, evening and night-time consultations. RESULTS: On the last Saturday of January there was a total of 45 088 consultations. On Christmas Eve the total number was 36 045 (80 % of Saturday) and on New Year's Eve the total was 50 377 (112 % of Saturday). Overnight on Saturday there was a total of 1 007 consultations concerning injuries. On the night of Christmas Eve, the figure was 453 (45 % of Saturday), while on the night of New Year's Eve it was 2 447 (243 % of Saturday). On New Year's Eve there were 246 night-time consultations associated with burns. The corresponding figure was 13 for Christmas Eve (5 % of New Year's Eve night-time) and 11 for Saturday (4 % of New Year's Eve night-time). On New Year's Eve there were 120 night-time consultations due to eye injuries. The corresponding figure for Christmas Eve was 16 (13 % of New Year's Eve night-time) and 23 for Saturday (19 % of New Year's Eve night-time). On New Year's Eve there were 513 night-time consultations due to acute alcohol intoxication. The corresponding figure for Christmas Eve was 53 (10 % of New Year's Eve night-time), and 260 for Saturday (51 % of New Year's Eve night-time). INTERPRETATION: Christmas Eve is peaceful in emergency primary care units, while New Year's Eve is probably the busiest night of the year. A ban on private firework displays may reduce the extent of injuries on New Year's Eve.

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

BACKGROUND: Primary care doctors have a gatekeeper function in many healthcare systems, and strategies to reduce emergency hospital admissions often focus on general practitioners' (GPs') and out-of-hours (OOH) doctors' role. The aim of the present study was to investigate these doctors' role in emergency admissions to somatic hospitals in the Norwegian public healthcare system, where GPs and OOH doctors have a distinct gatekeeper function. METHODS: A cross-sectional analysis was performed by linking data from the Norwegian Patient Registry (NPR) and the physicians' claims database. The referring doctor was defined as the physician who had sent a claim for a consultation with the patient within 24 h prior to an emergency admission. If there was no claim registered prior to hospital arrival, the admission was defined as direct, representing admissions from ambulance services, referrals from nursing home doctors, and admissions initiated by in-hospital doctors. RESULTS: In 2014 there were 497,845 emergency admissions to somatic hospitals in Norway after excluding birth related conditions. Referrals by OOH doctors were most frequent (36%), 35% were direct admissions, 28% were referred by GPs, whereas only 2% were referred from outpatient clinics or private specialists with public contract. Direct admissions were more common in central areas (45%), here GPs' referrals constituted only 18%. The prehospital paths varied with the hospital discharge diagnosis. For anaemias, 52­56% were referred by GPs, for acute appendicitis and mental/alcohol related disorders 57% and 56% were referred by OOH doctors, respectively. For malignant neoplasms 56% and cardiac arrest 57% were direct admissions. CONCLUSIONS: GPs or OOH doctors referred many emergencies to somatic hospitals, and for some clinical conditions GPs' and OOH doctors' gatekeeping role was substantial. However, a significant proportion of the emergency admissions was direct, and this reduces the impact of the GPs' and OOH doctors' gatekeeper roles, even in a strict gatekeeping system.

Doctors' characteristics and the use of long consultations at out-of-hours services 2008-2017: a registry-based follow-up study in Norway.

Objective: The aim was to analyse whether there was a change in percentage of long consultations over a 10-year period, and whether individual doctors changed their use of time as they got more experience and specialisation during the same period. Design and setting: This is a registry based study encompassing all consultations in primary care out-of-hours service in Norway in 2008 and 2017. Subjects: For both years all doctors were included in cross sectional analyses. In addition, doctors who participated both years were included in a separate follow-up analysis. Main outcome measures: Long consultations (>20 min) were identified by a time fee in the claims' database. Results: There were 4610 doctors in 2008 and 5620 in 2017, 904 participated both years. In 2008 a time fee was claimed in 38% of consultations, in 2017 in 47%. Older doctors made less use of the time fee, as did doctors who had many consultations, regular general practitioners, and general practice specialists. The general practitioners who participated both years increased their use of the time fee from 33% to 38% of consultations. Those who specialised in general practice during the 10-year period increased their use of the time fee from 34% to 37%. Conclusions: Experienced doctors have fewer long consultations than inexperienced doctors. Over years there is a strong trend towards increasing the use of time fee during out-of-hours consultations. This trend is only partly offset by increasing the experience of the doctors. KEY POINTS Although consultation length may be associated with patient satisfaction there is also a cost-efficiency aspect to be taken into account •Percentage long consultations out-of-hours increased from 38% in 2008 to 47% in 2017 •Experienced doctors had fewer long consultations •Experience only partly offset the trend towards more long consultations.

Frequent attenders at primary care out-of-hours services: a registry-based observational study in Norway.

BACKGROUND: Out-of-hours (OOH) services are often consulted for problems that are non-urgent. Some of these patients are frequent attenders (FAs) who may constitute a heavy burden on the OOH service. The aim of the present study was to analyse FAs in a comprehensive material, covering all patients who have visited OOH services in Norway during a 10-year period. METHODS: FA was defined as a patient having ≥5 consultations during one year. A cohort of all 15,172 FAs in 2008 was followed until 2017, with a description of demographics, consultations, and diagnoses for each year. FAs in 2017 were also analysed with more extreme definitions (≥10, ≥20, ≥30 consultations). To analyse predictors for FA a logistic regression analysis was performed on the 2017 data. RESULTS: FAs constituted 2% of all patients (U-shaped age curve and female overrepresentation) and approximately 10% of all consultations each year. 59.8% of the cohort was never FA again, 17.7% had one relapse, 8.6% two, and 4.4% had three relapses. 22.8% was also a FA in 2009. Thereafter the percentage gradually declined to 6.2% in 2017. Only 0.8% of the original cohort were persistent FAs throughout the 10-year period. FAs were three times as likely to be given a psychological diagnosis as the average OOH patient, and this percentage increased in persistent and more extreme FAs. FAs tended to seek help at inconvenient hours (late evening and night), and increasingly so the more extreme they were. Also, they needed more consultation time and more often received home visits. The logistic regression analysis identified the following predictors for becoming FA (odds ratio = OR): Female (OR 1.17), age 0-1 years (OR 3.46), age 70+ (OR 1.57), small municipality (OR 1.61), psychological diagnosis (OR 10.00), social diagnosis (OR 5.97), cancer (OR 6.76), diabetes (OR 4.65), and chronic obstructive pulmonary disease (OR 7.81). CONCLUSIONS: FAs were most common among the youngest children and among the elderly, increasing with age. Females were overrepresented, as were patients with psychosocial problems and various chronic somatic conditions. The majority were only temporary FAs.

Comparing unplanned and potentially planned home deaths: a population-based cross-sectional study.

BACKGROUND: There is little research on number of planned home deaths. We need information about factors associated with home deaths, but also differences between planned and unplanned home deaths to improve end-of-life-care at home and make home deaths a feasible alternative. Our aim was to investigate factors associated with home deaths, estimate number of potentially planned home deaths, and differences in individual characteristics between people with and without a potentially planned home death. METHODS: A cross-sectional study of all decedents in Norway in 2012 and 2013, using data from the Norwegian Cause of Death Registry and National registry for statistics on municipal health and care services. We defined planned home death by an indirect algorithm-based method using domiciliary care and diagnosis. We used logistic regressions models to evaluate factors associated with home death compared with nursing home and hospital; and to compare unplanned home deaths and potentially planned home deaths. RESULTS: Among 80,908 deaths, 12,156 (15.0%) were home deaths. A home death was most frequent in 'Circulatory diseases' and 'Cancer', and associated with male sex, younger age, receiving domiciliary care and living alone. Only 2.3% of home deaths were from 'Dementia'. In total, 41.9% of home deaths and 6.3% of all deaths were potentially planned home deaths. Potentially planned home deaths were associated with higher age, but declined in ages above 80 years for people who had municipal care. Living together with someone was associated with more potentially planned home deaths for people with municipal care. CONCLUSION: There are few home deaths in Norway. Our estimations indicate that even fewer people than anticipated have a potentially planned home death.

Point-of-care ultrasonography in Norwegian out-of-hours primary health care.

OBJECTIVE: The objective of this study is to determine the extent of ultrasound availability in Norwegian casualty clinics and estimate the prevalence of its use. DESIGN: A retrospective study based on a national casualty clinic registry and data from reimbursement claims. SETTING: Out-of-hours primary health care in Norway. SUBJECTS: All Norwegian casualty clinics in 2016 and reimbursement claims from 2008 to 2015. MAIN OUTCOME MEASURES: Percent of casualty clinics with ultrasound, types of ultrasound devices and probes, reasons for/against ultrasound access, characteristics of clinics with/without ultrasound, frequency of five ultrasound indications and characteristics of the physicians using/not using ultrasound. RESULTS: Out of 182 casualty clinics, 41 (23%) reported access to ultrasound. Mobile (49%) and stationary (44%) devices were most frequent. Physician request was the most common cited reason for ultrasound access (66%). Neither population served by the casualty clinic nor distance to hospital showed any clear association with ultrasound access. All of the five ultrasound reimbursement codes showed a substantial increase from 2008 to 2015 with 14.1 ultrasound examinations being performed per 10,000 consultations in 2015. Only 6.5% of physicians performed ultrasound in 2015 and males were significantly more likely to use ultrasound than females (OR 1.85, 95% CI: 1.38-2.47, p < .001), even when adjusted for age, speciality status and geography. CONCLUSIONS: Although the use of ultrasound is increasing in out-of-hours Norwegian primary health care, most casualty clinics do not have access and only a minority of physicians use ultrasound.