Community-based homecare nursing in Denmark: exploring factors related to substitution of nurses by ancillary health professionals.

BACKGROUND: Demographic changes and shorter hospital stays have made community-based homecare nursing an increasingly important part of the healthcare organisation. This development may also impact the secondary healthcare system. Optimal use of resources is key to meeting the future challenges. Nevertheless, the research-based knowledge on homecare nursing is scarce. The aim of this study was to examine factors related to homecare nursing tasks that could have been performed by ancillary health professionals. METHODS: A population-based survey involving all homecare nurses in the homecare services in one municipality in Denmark was performed. The nurses registered all contacts during daytime for one week using a registration form with a series of items to identify factors related to possible substitution of nurse-performed tasks. Statistical analyses were used to identify associations between specific factors and potential substitution of the performing type of healthcare professional. The study was approved by and is registered at VIA University College in accordance with the General Data Protection Regulation of the EU. RESULTS: Homecare nurses registered 941 representative visits in the municipality. Substitution by ancillary health professionals was considered a possibility by the nurses in 28.3% of the cases. When adjusting for age, gender, type of visit, need for extra healthcare services and vulnerability, we established that the nurses more often found that ancillary health professionals could have provided the care in unplanned visits and in visits to patients above 90 years of age. CONCLUSIONS: The results indicate potential for optimising the available nursing resources as substitution by ancillary health professionals was considered possible in numerous visits. In view of the increasing demands for community-based homecare nursing, it is important to make the most of the available resources in the future. Substitution of nurses for some tasks could be a feasible solution.

Age-related differences in motives for contacting out-of-hours primary care: a cross-sectional questionnaire study in Denmark.

OBJECTIVE: Demands for out-of-hours primary care (OOH-PC) services are increasing. Many citizens call because of non-urgent health problems. Nevertheless, the patients' motives for requesting medical help outside office hours remains an understudied area. This study aimed to examine motives for calling OOH-PC services in various age groups. DESIGN: Cross-sectional paper based questionnaire study conducted during two weeks in 2015. SETTING: The OOH-PC services in two Danish regions. SUBJECTS: Randomly selected patients calling the two healthcare services and accepting to participate in the study received a questionnaire on patient characteristics, health problems, and 26 pre-defined motives based on the Andersen Behavioural Model. Multivariate regression analyses were conducted for various age groups to calculate the probability of each motive to be a significant factor for the decision to call. RESULTS: A total of 1,871 patients were included in the study; half were parents of children aged 0-12 years. Young adults (18 to 39 years) differed significantly from other age groups as they more often stated perceived barriers and benefits such as "Own GP no time available soon enough" and "Need for quick help because of work". CONCLUSION: Young adults more often perceive barriers and benefits, which may suggest af difference in expectations regarding the purpose of out-of-hours services and accessibility. Further research is needed to address this issue and further explore the potential gap between the citizens' expectations to the OOH-PC services and the prevailing health policies. Key points The out-of-hours primary healthcare services are increasingly contacted for non-urgent problems, but little is known about the citizens' motives for calling. Age is associated with differences in the perceived importance of various motives for calling out-of-hours care. Young adults are more often than other age groups motivated to call due to logistical issues, such as their job.

Patient motives for contacting out-of-hours care in Denmark: a cross-sectional study.

BACKGROUND: Patients in need of acute health care do not always contact the most suitable health care service provider. Contacting out-of-hours primary care for an urgent problem may delay care, whereas contacting emergency medical services for a non-urgent problem could ultimately affect patient safety. More insight into patient motives for contacting a specific health care provider may help optimise patient flows. This study aims to explore patient motives for contacting out-of-hours primary care and the emergency medical services in Denmark. METHODS: We conducted a cross-sectional observational study by sending a questionnaire to patients contacting out-of-hours primary care and emergency medical services, both of which can be directly contacted by patients, in two of five Danish regions in 2015. As we aimed to focus on the first access point, the emergency department was not included. The questionnaire included items on patient characteristics, health problem and 26 pre-defined motives. Descriptive analyses of patient characteristics and motives were conducted, stratified by the two health care service providers. Factors associated with contacting each of the two service providers were explored in a modified Poisson regression analysis, and adjusted risk ratios were calculated. RESULTS: Three key motives for contacting the two service providers were identified: 'unpleasant symptoms', 'perceived need for prompt action' and 'perceived most suitable health care provider'. Other important motives were 'need arose outside office hours' and 'wanted to talk to a physician' (out-of-hours primary care) and 'expected need for ambulance' and 'worried' (emergency medical services). Higher probability of contacting the emergency medical services versus out-of-hours primary care was seen for most motives relating to own assessment and expectations, previous experience and knowledge, and own needs and wishes. Lower probability was seen for most motives relating to perceived barriers and benefits. CONCLUSIONS: Patient motives for contacting the two health care service providers were partly overlapping. The study contributes with new knowledge on the complex decision-making process of patients in need of acute health care. This knowledge could help optimise existing health care services, such as patient safety and the service level, without increasing health care costs.

Preschool children in Danish out-of-hours primary care: a one-year descriptive study of face-to-face consultations.

BACKGROUND: The demand for out-of-hours (OOH) primary care has increased during the last decades, with a considerable amount of contacts for young children. This study aims to describe the reasons for encounter (RFE), the most common diagnoses, the provided care, and the parental satisfaction with the general practitioner (GP) led OOH service in a Danish population of children (0-5 years). METHODS: We conducted a one-year cross-sectional study based on data for 2363 randomly selected contacts concerning children from a survey on OOH primary care including 21,457 patients in Denmark. For each contact, the GPs completed an electronic pop-up questionnaire in the patient's medical record. Questionnaire items focussed on RFE, health problem severity, diagnosis, provided care, and satisfaction. The parents subsequently received a postal questionnaire. RESULTS: The most common RFE was non-specific complaints (40%), followed by respiratory tract symptoms (23%), skin symptoms (9%), and digestive organ symptoms (8%). The most common diagnosis group was respiratory tract diseases (41%), followed by general complaints (19%) and ear diseases (16%). Prescriptions were dispensed for 27% of contacts, and about ¾ were for antibiotics. A total of 12% contacts concerned acute otitis media; antibiotics were prescribed in 70%. A total of 38% of contacts concerned fever, and » got antibiotics. A total of 7.4% were referred for further evaluation. The parental satisfaction was generally high, but 7.0% were dissatisfied. Dissatisfaction was correlated with low prescription rate. CONCLUSION: Respiratory tract diseases were the most common diagnoses. The GPs at the OOH primary care service referred children to hospital in 7.4% of the face-to-face consultations, and the provided care was evaluated as non-satisfying by only 7.0% of the parents. Clinical implications of the findings mean room for less prescription of antibiotic to children with ear diseases and a need for research in factors related to dissatisfaction.

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.

Factors associated with low patient satisfaction in out-of-hours primary care in Denmark - a population-based cross-sectional study.

BACKGROUND: Low patient satisfaction with the quality of out-of-hours primary care (OOH-PC) has been linked with several individual and organizational factors. However, findings have been ambiguous and may not apply to the Danish out-of-hours (OOH) setting in which general practitioners (GPs) perform the initial telephone triage. This study aimed to identify patient-related, GP-related and organizational factors associated with low patient satisfaction. METHODS: The study was based on data from a 1-year population-based survey of OOH-PC (LV-KOS) in the Central Denmark Region in 2010-2011. GPs on OOH duty completed an electronic questionnaire in the OOH computer system, and the registered patients received a subsequent postal questionnaire focusing on contact evaluation, waiting time, demographic characteristics and general self-perceived health. Associations were analysed using multivariable logistic regression with dissatisfaction as the dependent variable. RESULTS: The patient response rate was 50.6%. For all contact types, 82.5% of the patients were satisfied with the OOH-PC service. More patients were dissatisfied with telephone consultations than with clinic consultations or home visits (8.5% vs. 6.0% and 4.3%, respectively). Contacts assessed by the GP as 'not severe' were associated with dissatisfaction for telephone consultations and home visits. Poor general self-perceived health was associated with dissatisfaction for all contact types. Living in urban areas was associated with dissatisfaction for telephone consultations, while unacceptable waiting time was associated with dissatisfaction for all contact types. CONCLUSIONS: We found a high level of patient satisfaction with the OOH-PC service. The only factors affecting patient satisfaction across all contact types were unacceptable waiting time and poor general self-perceived health. For the other investigated factors, patient satisfaction depended on the type of contact. Generally, patients contacting for GP-assessed non-severe health problem and patients living in urban areas were more dissatisfied.

Preschool children in out-of-hours primary care - a questionnaire-based cross-sectional study of factors related to the medical relevance of health problems.

BACKGROUND: Out-of-hours primary care (OOH-PC) is intended to provide medical care services for health problems that cannot wait until normal office hours. Children under five years of age represent about 19% of all OOH-PC contacts in Denmark, and the frequency of calls assessed as severe by health professionals is markedly lower for children than for other age groups. Several studies have questioned the appropriateness of the parents' use of OOH-PC. We aimed to identify factors associated with calls from parents of pre-school children concerning perceived non-severe health problems that were ranked by the triaging GPs as more appropriate for GP office hours (defined as 'medically irrelevant'). METHODS: We used data from a cross-sectional study performed in the Central Denmark Region for a 1-year period during 2010-2011. GPs in the OOH-PC assessed random contacts, and a questionnaire was subsequently sent to registered patients. Associations between different factors and the medical irrelevance of contacts were estimated with a generalised linear model to calculate the prevalence ratio (PR). RESULTS: Among all included 522 telephone consultations and 1226 face-to-face consultations, we identified 71 (13.6%) telephone consultations and 95 (7.8%) face-to-face consultations that were both assessed as non-severe by the parents and more appropriate for GP office hours by the GPs. For telephone consultations, contacts at other times than 4-8 pm on weekdays were statistically significantly associated with medical irrelevance. Additionally, symptoms of longer duration than 24 h were statistically significantly associated medical irrelevance. CONCLUSIONS: A large part of the calls to the Danish OOH-PC concern children. The results indicate that some of these calls are made for other than strictly medical reasons. To achieve more effective use of available resources, it might seem relevant to aim at directing more contacts directly to daytime care. However, future studies to enhance our knowledge on parents' motivation and behaviour would be recommendable.

Medical appropriateness of adult calls to Danish out-of-hours primary care: a questionnaire-based survey.

BACKGROUND: Optimal utilisation of the out-of-hours primary care (OOH-PC) services remains a concern in public health policy. We need more knowledge on potentially avoidable contacts. This study examines the frequency of medically assessed inappropriate OOH-PC calls from adults, explores factors associated with such assessment, and examines the relation to patient-assessed severity of health problem and fulfilment of expectations. METHODS: We performed secondary analyses of data from a large cross-sectional survey on contacts to Danish OOH-PC. As access to Danish OOH-PC is provided through telephone triage delivered by a general practitioner (GP), we included only telephone contacts. A contact was characterised as medically inappropriate when the triage GP assessed that the request from a medical perspective should have been directed to daytime primary care. Appropriateness was examined in relation to patient characteristics, reason for encounter, time of contact, and whether the contact was triaged to a face-to-face consultation, and in relation to patient-assessed severity of the health problem and fulfilment of expectations. Associations were estimated with odds ratios (ORs) using multivariate analysis. RESULTS: Of all contacts, 23.7% were assessed as medically inappropriate. Such assessment was associated with: younger age, longer symptom duration, exacerbation of chronic condition, and contact only few hours away from own GP's office hours. Of medically inappropriate contacts, 31.3% were from patients aged 18-30 years, 41.5% concerned symptoms of > 24 h, 19.4% concerned exacerbation of chronic condition, and 21.3% were calls < 3 h away from own GP's regular office hours. Medicine request was the most frequent reason for an inappropriate contact (14.3% of medically inappropriate contacts). In 53.4% of contacts assessed as inappropriate, the health problem was considered as severe by patients and medical assessed inappropriateness was significantly associated with unfulfilled patient expectations. CONCLUSIONS: One in four OOH-PC calls was considered medically inappropriate. Future efforts to reduce suboptimal use of OOH-PC should focus on the types of contacts with the highest optimisation potential, e.g., medication requests, long-lasting symptoms, and exacerbations. Such interventions should aim at bridging the gap between the GP's medical assessment and the patient's expectations to appropriate OOH-PC use.

Drug prescriptions in Danish out-of-hours primary care: a 1-yearpopulation-based study.

OBJECTIVE: General practitioners are the first point of contact in Danish out-of-hours (OOH) primary care. The large number of contacts implies that prescribing behaviour may have considerable impact on health-care expenditures and quality of care. The aim of this study was to examine the prevailing practices for medication prescription in Danish OOH with a particular focus on patient characteristics and contact type. DESIGN AND SETTING: A one-year population-based retrospective observational study was performed of all contacts to OOH primary care in the Central Denmark Region using registry data. MAIN OUTCOME MEASURES: Prescriptions were categorised according to Anatomical Therapeutic Chemical Classification (ATC) codes and stratified for patient age, gender and contact type (telephone consultation, clinic consultation or home visit). Prescription rates were calculated as number of prescriptions per 100 contacts. RESULTS: Of 644,777 contacts, 154,668 (24.0%) involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits. Around 53% of all drug prescriptions were made in telephone consultations. Anti-infective medications for systemic use accounted for 45.5% of all prescriptions and were the most frequently prescribed drug group for all contact types, although accounting for less than 1/3 of telephone prescriptions. Other frequently prescribed drugs were ophthalmological anti-infectives (10.5%), NSAIDs (6.4%), opioids (3.9%), adrenergic inhalants (3.0%) and antihistamines (2.3%). CONCLUSION: About 25% of all OOH contacts involved one or more medication prescriptions. The highest prescription rate was found for clinic consultations, but more than half of all prescriptions were made by telephone. KEY POINTS As the out-of-hours (OOH) primary care services cover more than 75% of all hours during a normal week, insight into the extent and type of OOH drug prescription is important. General practitioners (GPs) are responsible for more than 80% of all drug prescriptions in Denmark. Of all contacts 24.0% involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits. Of all prescriptions, 53% were made in telephone consultations. Anti-infective medications for systemic use accounted for 45.5% of all prescriptions, thereby being the most frequently prescribed drug group for all three contact types.

Telephone triage by GPs in out-of-hours primary care in Denmark: a prospective observational study of efficiency and relevance.

BACKGROUND: In the UK, telephone triage in out-of-hours primary care is mostly managed by nurses, whereas GPs perform triage in Denmark. AIM: To describe telephone contacts triaged to face-to-face contacts, GP-assessed relevance, and factors associated with triage to face-to-face contact. DESIGN AND SETTING: A prospective observational study in Danish out-of-hours primary care, conducted from June 2010 to May 2011. METHOD: Information on patients was collected from the electronic patient administration system and GPs completed electronic questionnaires about the contacts. The GPs conducting the face-to-face contacts assessed relevance of the triage to face-to-face contacts. The authors performed binomial regression analyses, calculating relative risk (RR) and 95% confidence intervals. RESULTS: In total, 59.2% of calls ended with a telephone consultation. Factors associated with triage to a face-to-face contact were: patient age >40 years (40-64: RR = 1.13; >64: RR = 1.34), persisting problem for 12-24 hours (RR = 1.15), severe problem (RR = 2.60), potentially severe problem (RR = 5.81), and non-severe problem (RR = 2.23). Face-to-face contacts were assessed as irrelevant for 12.7% of clinic consultations and 11.7% of home visits. A statistically significantly higher risk of irrelevant face-to-face contact was found for a persisting problem of >24 hours (RR = 1.25), contact on weekday nights (RR = 1.25), and contact <2 hours before the patient's own GP's opening time (RR = 1.80). CONCLUSION: Around 12% of all face-to-face consultations in the study are assessed as irrelevant by GP colleagues, suggesting that GP triage is efficient. Knowledge of the factors influencing triage can provide better education for GPs, but future studies are needed to investigate other quality aspects of GP telephone triage.