A named General Practitioner (GP) is associated with an increase of hospital days in a single predictor analysis: a follow-up of 15 years.

BACKGROUND: Continuity of care constitutes the basis of primary health care services and is associated with decreased hospitalization. In Finland, accessibility to primary care and increased use of hospital services are recognized challenges for the health care system. OBJECTIVES: The aim of the study was to determine whether having a named GP is associated with hospital service use. METHODS: The data are part of the Health and Social Support study (HeSSup) based on a random Finnish working-age population sample. The cohort of the study comprised participants of postal surveys in 1998 (n = 25,898) who returned follow-up questionnaires both in 2003 and 2012 (n = 11,924). Background characteristics were inquired in the questionnaires, and hospitalization was derived from national registries (Hilmo-register). RESULTS: A named GP was reported both in 2003 and 2012 only by 34.3% of the participants. The association between hospital days and a named GP was linearly rising and statistically significant in a single predictor model. The strongest associations with hospital use were with health-related factors, and the association with a named GP was no longer significant in multinomial analysis. CONCLUSION: A named GP is associated with an increased use of hospital days, but in a multinomial analysis the association disappeared. Health related factors showed the strongest association with hospital days. From the perspective of the on-going Finnish health and social services reform, continuity of care should be emphasized.

A named GP increases self-reported access to health care services.

BACKGROUND: Continuity of care strengthens health promotion and decreases mortality, although the mechanisms of these effects are still unclear. In recent decades, continuity of care and accessibility of health care services have both decreased in Finland. OBJECTIVES: The aim of the study was to investigate whether a named and assigned GP representing continuity of care is associated with the use of primary and hospital health care services and to create knowledge on the state of continuity of care in a changing health care system in Finland. METHODS: The data are part of the Health and Social Support (HeSSup) mail survey based on a random Finnish working age population sample of 64,797 individuals drawn in 1998 and follow-up surveys in 2003 and 2012. The response rate in 1998 was 40% (n = 25,898). Continuity of care was derived from the 2003 and 2012 data sets, other variables from the 2012 survey (n = 11,924). The principal outcome variables were primary health care and hospital service use reported by participants. The association of the explanatory variables (gender, age, education, reported chronic diseases, health status, smoking, obesity, NYHA class of any functional limitation, depressive mood and continuity of care) with the outcome variables was analysed by binomial logistic regression analysis. RESULTS: A named and assigned GP was independently and significantly associated with more frequent use of primary and hospital care in the adjusted logistic regression analysis (ORs 1.53 (95% CI 1.35-1.72) and 1.19 (95% CI 1.08-1.32), p < 0.001). CONCLUSION: A named GPs is associated with an increased use of primary care and hospital services. A named GP assures access to health care services especially to the chronically ill population. The results depict the state of continuity of care in Finland. All benefits of continuity of care are not enabled although it still assures treatment of population in the most vulnerable position.

Whole exome sequencing study identifies novel rare and common Alzheimer's-Associated variants involved in immune response and transcriptional regulation.

The Alzheimer's Disease Sequencing Project (ADSP) undertook whole exome sequencing in 5,740 late-onset Alzheimer disease (AD) cases and 5,096 cognitively normal controls primarily of European ancestry (EA), among whom 218 cases and 177 controls were Caribbean Hispanic (CH). An age-, sex- and APOE based risk score and family history were used to select cases most likely to harbor novel AD risk variants and controls least likely to develop AD by age 85 years. We tested ~1.5 million single nucleotide variants (SNVs) and 50,000 insertion-deletion polymorphisms (indels) for association to AD, using multiple models considering individual variants as well as gene-based tests aggregating rare, predicted functional, and loss of function variants. Sixteen single variants and 19 genes that met criteria for significant or suggestive associations after multiple-testing correction were evaluated for replication in four independent samples; three with whole exome sequencing (2,778 cases, 7,262 controls) and one with genome-wide genotyping imputed to the Haplotype Reference Consortium panel (9,343 cases, 11,527 controls). The top findings in the discovery sample were also followed-up in the ADSP whole-genome sequenced family-based dataset (197 members of 42 EA families and 501 members of 157 CH families). We identified novel and predicted functional genetic variants in genes previously associated with AD. We also detected associations in three novel genes: IGHG3 (p = 9.8 × 10-7), an immunoglobulin gene whose antibodies interact with ß-amyloid, a long non-coding RNA AC099552.4 (p = 1.2 × 10-7), and a zinc-finger protein ZNF655 (gene-based p = 5.0 × 10-6). The latter two suggest an important role for transcriptional regulation in AD pathogenesis.

Correction: Whole exome sequencing study identifies novel rare and common Alzheimer's-Associated variants involved in immune response and transcriptional regulation.

A correction to this paper has been published and can be accessed via a link at the top of the paper.

Stroke and cardiovascular risk factors among working-aged Finnish migraineurs.

BACKGROUND: The aim of our study was to evaluate the risk for comorbid cardio- and cerebrovascular diseases in the working-aged migraine population of Finland. METHODS: A total of 1505 cases who reported diagnosed migraine and 3010 controls from a cohort of 11,596 cases in the Finnish Health and Social Support Study were included. The study material was linked with two registers. ICD diagnoses I63 for ischemic stroke (IS), I21 - I22 for acute myocardial infarction (AMI), and G43 for transient ischemic attack (TIA) among study participants were drawn from the national Finnish Care Register for Health Care at the follow-up in 2012. Reimbursed triptan prescriptions were drawn from the national Social Security Institution (SII) data. The self-reported vascular risk factors were hypertension, high cholesterol values, any diabetes, myocardial infarction, stroke, and TIA. Odds Ratios (OR) with 95% confidence (95% CI) intervals were assessed for diagnosed stroke, myocardial infarction, and TIA. RESULTS: Migraineurs were mostly female (82%) and ≥ 54 years old (62%). Triptans were reimbursed among 34.7% of migraineurs. A self-reported hypertension (21%), high serum cholesterol (38%), and any diabetes (7%) were more common among migraineurs vs controls (p < 0.05). There was no risk for AMI. The risk for TIA (OR 3.20, 95% CI 1.45-7.05) and IS (2.57, 95% CI 1.28-5.17) among migraineurs vs controls remained high after adjustment for self-reported hypertension, obesity, and smoking. The risk was higher among women in two groups ≥54 years (3.25, 95% CI 1.35-7.84 and 5.0, 95% CI 1.94-12.89, respectively). The average age for IS in migraine was 57.5 years and for TIA 58.2 years among women, and 52.8 years and 50.3 years among men, respectively. CONCLUSION: Cardiovascular risk should be screened in the aging migraine population, and hormonal and other migraine-related risk factors should be considered, especially among women. Efficacious attack treatment with triptans should be offered to migraine patients who do not show contraindications.

Research orientation among general practitioners compared to other specialties.

OBJECTIVE: The volume of research work done by general practitioners (GP) is modest compared to other specialties. In order to find out reasons for this we examined the current situation concerning research orientation and factors relating to them among Finnish GPs compared to other specialists. DESIGN AND SETTING: Data from The Physician 2018 Study were used for our research. The study was undertaken in collaboration with all five medical faculties in Finland and the Finnish Medical Association. It compiled information on physicians` social background, work history and career and research plans as well as their views regarding undergraduate and specialist training, values, and professional identity. SUBJECTS: The basic study population comprised all Finnish doctors under 70 years of age (N = 23,131). Questionnaires were sent to doctors born on even-numbered days (n = 11,336). Altogether 5,214 (45.8%) responded. Responses from GPs (n = 796) were compared with those of doctors in other specialties (n = 3,514). MAIN OUTCOME MEASURES AND RESULTS: The respondents were asked about their current intention to undertake a doctoral degree. Factors associated with this were analysed. Only 7.3% of GPs had completed a doctoral degree. The corresponding figure in other specialties was 32.3% (p < 0.001). In general practice the current intention to undertake a doctoral degree had only slightly increased over ten years. Most GPs had also decided not to undertake a doctorate. The main factors associated with the current intention to complete a doctoral degree were interest in attaining a senior position (OR 3.43, 95% CI 2.25-5.24), a position in a university hospital district (OR 2.89, 95% CI 1.69-4.94) or other sector than primary care (OR 1.87, 95% CI 1.18-2.96), one's father being a doctor (OR 2.01, 95% CI 1.09-3.72) and male gender (OR 1.63, 95% CI 1.05-2.54). CONCLUSION: Research work in primary health care has been quite sparse. In general practice there is a need to increase teaching and guidance in research work.Key pointsResearch work in primary health care is not very common.Only 7.3% of GPs had completed their doctorate compared to 32.3% in other specialties.A main factor associated with the current intention to complete a doctoral degree was interest in attaining a senior position.

Intrahepatic cholestasis of pregnancy and comorbidity: A 44-year follow-up study.

INTRODUCTION: Intrahepatic cholestasis of pregnancy (ICP) is a reversible liver disorder occurring during pregnancy. It has a typical genetic background with known genetic mutations and can be considered an expression of this genetic predisposition. The objective of this study was to determine whether ICP is associated with specific long-term comorbidity. MATERIAL AND METHODS: The study population comprised 571 women with ICP in at least one pregnancy who were compared with 1333 pregnant women without ICP during 1969-1988 at Tampere University Hospital, Finland. The cohort's follow-up time was 44 years. All ICD-10 classification discharge diagnoses were examined for the women in the ICP group from 1998 to 2013 and ICD-10 diagnoses from outpatient care from 1969 to 2013. RESULTS: At least one disease of the digestive system had been diagnosed in 50.4% (288/571) of the ICP mothers compared with 34.4% (459/1333) of the reference group (P < 0.001). In a more detailed analysis, women with a history of ICP had an increased risk for cholelithiasis and/or cholecystitis (odds ratio [OR] 2.88, 95% confidence interval [CI] 2.17 to 3.84), diseases of the pancreas (OR 2.26, 95% CI 1.20 to 4.27) and hypothyroidism (OR 2.38, 95% CI 1.27 to 4.46) compared with the reference group. Arterial diseases were less common in the ICP mothers than in the reference group (OR 0.38, 95% CI .15 to .99). Regarding other diseases, there were no statistically significant differences between the ICP mothers and reference group. CONCLUSIONS: Half of the women with a history of ICP were diagnosed with at least one disease of the digestive system compared with a third in the reference group. The risk of cholelithiasis, cholecystitis, diseases of the pancreas and hypothyroidism was increased compared with the reference group. These are important facts when counseling women after a pregnancy with ICP. Also, this is of importance for the general practitioners and other physicians who take care of these women.

Intrahepatic cholestasis of pregnancy and associated causes of death: a cohort study with follow-up of 27-46 years.

BACKGROUND: The aim of this study was to determine whether intrahepatic cholestasis of pregnancy (ICP) is associated with causes of death during on average 35 years follow-up after the delivery. METHODS: The study population comprised 571 women with ICP in at least one pregnancy seen at Tampere University Hospital, Finland, between 1969 and 1988. ICP was verified from patient records. The previous and following subjects in the maternity ward diary were taken as controls for each ICP case. In total, there were 1333 controls. All underlying causes of death were obtained from Statistics Finland in March 2017. The deaths occurred during 1971-2015 and the causes of death were classified according to ICD-10. RESULTS: Altogether, 39 of the mothers with ICP (6.8%) and 111 of the controls (8.3%) had died by the end of 2015 (p = 0.267). There were more underlying causes of death from gastrointestinal diseases (15%) in the ICP group than in the control group (4%) (p = 0.011). The number of underlying causes of death due to diseases of the circulatory system were lower in the ICP group (13%) than in the control group (26%), although the finding was not statistically significant (p = 0.088). Moreover, neoplasms were the underlying cause of death in 46% of cases among mothers with ICP and in 41% of cases among the controls (p = 0.609). Diseases of the other organ systems were rare in both groups. CONCLUSION: Women with a history of ICP do not have an increased overall mortality. However, deaths from gastrointestinal diseases are overrepresented among women with a history of ICP.

What predicts doctors' satisfaction with their chosen medical specialty? A Finnish national study.

BACKGROUND: In Finland the number of medical specialists varies between specialties and regions. More regulation of the post-graduate medical training is planned. Therefore, it is important to clarify what predicts doctors' satisfaction with their chosen specialty. METHODS: A random sample contained 50% of all Finnish doctors under 70 years of age. The respose rate was 50.5%. Working-age specialists were asked to value their motives when choosing a specialty. They were also asked if they would choose the same specialty again. The odds ratios for not choosing the same specialty again were tested. RESULTS: Diversity of work was the most important motive (74% of respondents). Seventeen percent of GPs would not choose the same specialty again, compared to 2% of ophthalmologists and 4% of pediatricians. A major role of Diversity of work and Prestigious field correlated with satisfaction whereas Chance with dissatisfaction with the specialty. DISCUSSION: Motives and issues related to the work and training best correlate with satisfaction with the specialty. CONCLUSIONS: When the numbers of Finnish postgraduate medical training posts become regulated, a renewed focus should be given to finding the most suitable speciality for each doctor. Information about employment and career advice should play an important role in this.

Flawed oral health of a non-smoking adolescent suggests smoking in adulthood.

BACKGROUND: Smokers often have oral health problems. We studied whether poor oral health among non-smoking adolescents is connected to smoking behaviour in adulthood. METHODS: We used an age cohort born in 1979 (n = 2582) taking part in annual oral health check-ups between the ages of 13 and 15. Self-reported non-smokers were used as the study population. As measures we used decayed, missing or filled teeth/surfaces (DMF) and decayed teeth (D) and smoking behaviour at ages 13-15 and the depending measure was smoking behaviour at the age of 29. RESULTS: Those who were non-smokers at ages 13-15 and had tooth decay (D > 0) in an oral check-up during that period had higher risk (OR (Odds Ratio) 1.88, 95% confidence interval 1.2-2.9) of being a smoker by age 29. Tooth decay at age 15 predicted earlier onset of smoking for those, who became smokers later in life. Dental caries (DMF > 0) was not associated with higher risk of becoming a smoking adult, but those with dental caries at age 13 were more likely to start smoking earlier. CONCLUSIONS: Poorer dental health, especially tooth decay in adolescence is a possible indicator of a greater likelihood of transforming from being a non-smoker to a smoker. Dentists should notice this for allocated health promotion.

Factors important in the choice of a medical career: a Finnish national study.

BACKGROUND: Applying for medical school is the first and also one of the most important career choices a physician makes. It is important to understand the reasons behind this decision if we are to choose the best applicants for medical schools and enable them to pursue satisfying careers. METHODS: Respondents to the Finnish Junior Physician 88, Physician 1998 and Physician 2008 studies were asked: "To what extent did the following factors influence your decision to apply for medical school?" In 1998 and 2008 the respondents were also asked: "If you were starting your studies now, would you start studying medicine?" and had to answer "Yes" or "No". The odds ratios for the answer "No" were tested using logistic regression models. RESULTS: "Interest in people" was the main motive for starting to study medicine. "Good salary" and "Prestigious profession" were more important motives for males and "Vocation" and "Interest in people" for females. There were some significant changes in the motives for entering medicine in the 20-year period between studies. "Vocation" and "Wide range of professional opportunities" as important motives for entering medicine predicted satisfaction with the medical profession. DISCUSSION: Strong inner motivation may indicate the ability to adapt to the demands of work as a physician. CONCLUSIONS: Medical schools should try to select those applicants with the greatest vocational inclination towards a medical career.

[Finnish language proficiency of immigrant physicians in medical licensure examinations]. / Maahanmuuttajataustaisten lääkärien suomen kielen taito laillistamiskuulustelussa.

BACKGROUND: Physicians immigrating to Finland from countries outside the EU/EEA must pass a language test and three medical licensure examinations (MLE) in Finnish. Failing rates are high and remarkably variable. MATERIAL AND METHODS: MLE examination papers were analyzed with linguistic criteria: writing skills and word frequency. Results of the linguistic analyses were compared with the MLE scores. RESULTS: Better results in writing skills analysis correlate with higher scores in MLE. Also a higher portion of rare words correlates with higher scores in MLE. CONCLUSIONS: The mandatory language test does not serve as a valid measurement tool for immigrant physicians.

Decreasing trends in patient satisfaction, accessibility and continuity of care in Finnish primary health care - a 14-year follow-up questionnaire study.

BACKGROUND: The aim here was to explore trends in patient satisfaction with primary health care and its accessibility and continuity, and to explore whether through reforms and improvements some of the essential goals had been achieved over a 14-year period of time in Finland. METHODS: Nine questionnaire surveys were conducted over a period of 14 years among patients attending within one week in the 65 health centres in the Tampere University Hospital catchment area. A total of 147,394 responded out of a sample of 333,648 patients. The response rate varied yearly from 53% to 37%. RESULTS: Patient satisfaction with care in Finnish health centres decreased by nearly 9 percentage units from 1998 to 2011. The fall-off was most marked in the age-group over 64 years. There was a 20 percentage unit's reduction in ease of access as reported by patients. Respondents also reported that the continuity of care had deteriorated. CONCLUSIONS: Despite major reforms in Finnish health care policy, patients seem to be less satisfied. Our findings challenge both Finnish authorities and GPs to improve the accessibility and continuity of care in primary health services.

Reactions and attitudes to postpartal mental symptoms in a rural community.

We examined the reactions of population, social and health care professionals and local politicians in the context of a narrative case of a newborn and her mother evincing postpartal mental symptoms. The results of this postal questionnaire study indicated that in assessing the urgent need for support, a significant positive association prevailed in the resident cohort with female gender, age over 50 years or being a parent. Professionals and politicians estimated that appropriate care and access to care would be obtained in the maternity and child health clinic in the local health centre. Residents would contact relatives rather than social and health care professionals. A future challenge is to promote the knowledge and sensitivity of the general population in recognizing mental symptoms in mothers with small children. Adequate information is also called for regarding local services and means of access to care.

Intrahepatic cholestasis of pregnancy is common among patients' first-degree relatives.

Intrahepatic cholestasis of pregnancy has been shown to have a genetic predisposition. We studied whether Finnish women who had suffered from the disorder reported their first-degree relatives to have had liver dysfunction during their pregnancies. Questionnaires were sent in autumn 2010 to a total of 544 former intrahepatic cholestasis of pregnancy patients and 1235 controls, all having delivered during 1969-1988. The response rate was 66.2%. The incidence of intrahepatic cholestasis is 0.5-1.5% of pregnancies in Finland. In our survey, altogether 12.8% of mothers (odds ratio 9.2), 15.9% of sisters (odds ratio 5.3) and 10.3% of daughters (odds ratio 4.8) of women who had suffered from intrahepatic cholestasis of pregnancy had had liver dysfunction during pregnancy. Our findings strengthen the earlier knowledge of the genetic component in intrahepatic cholestasis of pregnancy. We suggest that all pregnant women are asked about their family history regarding liver dysfunction during pregnancy.

Reactions to acute psychotic symptoms in a rural community.

BACKGROUND: Recognition of psychotic disorders constitutes a challenge to the population and health and social care. AIM: To evaluate the reactions of the general population, professionals in the health and social services, and local politicians in light of the symptoms of a patient evincing acute psychotic mental symptoms. MATERIAL AND METHODS: A postal questionnaire study was conducted in the rural Suupohja area in Finland. Three target groups: a randomized sample of residents aged 15-84 years (n = 1200), local social and healthcare personnel (n = 463) and politicians (n = 148) responded to alternatives in identifying the need and urgency of treatment. RESULTS: Seventy-six per cent of residents, 85% of politicians and 87% of health and social employees recognized that the patient was in need of urgent support and treatment. A significant positive association was found in the resident cohort between recognizing urgent need for support and female gender. Forty-eight per cent of inhabitants, 69% of social and healthcare staff, and 65% of politicians estimated that appropriate care and access to care would be obtained in the acute outpatient care of the health centre. CONCLUSION: Almost one quarter of residents were not aware of the patient's urgent need for acute mental healthcare. It is a challenge to promote the knowledge and sensitivity of the population in recognizing mental and psychotic symptoms. Also appropriate information is called for regarding local services and how to access the care.

Health history after intrahepatic cholestasis of pregnancy.

OBJECTIVE: To establish whether intrahepatic cholestasis of pregnancy (ICP) is associated with other diseases during a woman's lifetime. DESIGN: Prospective controlled cohort study. SETTING: University Hospital in Finland. POPULATION: A total of 575 women with ICP and 1374 control women, all having delivered in 1969-1988. Questionnaires were sent to 544 ICP patients and 1235 control women. Responses were received from 1178 (66.4%). METHODS: Questionnaire survey in autumn 2010. MAIN OUTCOME MEASURES: Perceived health, symptoms and complaints, diseases diagnosed by a doctor and use of medicines. RESULTS: No statistically significant differences were detected in perceived health. Differences in recent symptoms and complaints were small. Diagnoses made by a doctor showed higher frequencies in the ICP group than in control women for other hepatobiliary diseases, breast cancer and hypothyreosis. Diagnosed hypertension and high cholesterol requiring medication as well as cardiac arrhythmia were less frequent in the ICP group. Women in this group used antacid medicines more often than control women. CONCLUSIONS: There were few differences between the ICP patients and control women except for a higher frequency of later hepatobiliary disease, breast cancer and hypothyreosis. Women with a history of ICP should be screened for hypothyreosis more readily than those without. The higher frequency of breast cancer warrants further research.

Self-reported rather than registered cancer is associated with psychosocial strain.

BACKGROUND: Individuals with only a subjective experience of cancer may conceal severe psychological distress and act like patients with verified disease. The purpose of the study was to establish whether some typical psychosocial factors may be linked to subjects with registered cancer (confirmed) and also to those with self-reported cancer lacking accompanying registered data (non-confirmed). METHODS: The material comprised 25,898 working-aged individuals (response rate 40.0%) in 1998. Of these 19,629 also responded at the follow-up in 2003 (response rate 75.8%). The analyses focused on respondents with cancer diagnosis in 2002 or earlier according to data of the Finnish Cancer Registry and self-report of cancer in 2003 (confirmed) (N=330) and on respondents with self-reported cancer only but lacking registered diagnosis (non-confirmed) (N=140). Those who neither reported cancer nor had a diagnosis were included as a control group (N=18,299). RESULTS: Respondents with confirmed cancer belonged more often to the oldest age-group than those with non-confirmed cancer. Respondents with non-confirmed cancer were more often obese, depressed and reported less social support compared to subjects with confirmed cancer. Compared to controls they had a statistically significantly increased risk of depression, lower optimism, lower life satisfaction, more childhood adversities, more negative life events and less social support. CONCLUSIONS: Individuals with only a subjective experience of cancer reported more psychosocial strain than those with accompanying registered cancer. Self-report of a severe disease like cancer without corresponding clinical findings might reflect heavy psychological distress which should be taken into consideration in clinical work.

Where have all the GPs gone--where will they go? Study of Finnish GPs.

BACKGROUND: In this paper a specialist in general practice is referred to as a general practitioner (GP). In Finland only half of all GPs work as a health centre physician. The present aim was to establish what the working places of specializing and specialized physicians in general practice are, and where they assume they will work in the future. METHODS: The study population comprised 5,357 physicians licensed in Finland during the years 1977-1996. Altogether 2,956 questionnaires were returned, a response rate of 55.2%. Those either specializing (GP trainees, n=133) or already having specialized (GPs, n=426) in general practice were included in the study. Respondents were asked what kind of physician's work they would most preferably do. They were further asked what work they assumed they would be doing in the year 2020. RESULTS: Altogether 72% were working in public primary health centres and 14% in the private sector. Of GPs 53% and of GP trainees 70% would most preferably work in health centres. Of GPs 14% would most preferably work as private practitioners and 9% as occupational health physicians. Sixteen per cent assumed they would be working as private practitioners and 35% assumed they would be retired in the year 2020. Of GP trainees 57% assumed they would be working as health centre physicians in 2020. CONCLUSIONS: According to the present findings many experienced GPs will leave their work as a health centre physician. Moreover, several GP trainees do not consider health centre physician's work as a long-term career option. These trends may in the future reflect a recruiting problem in many primary health centres.

Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City.

BACKGROUND: Many Finnish emergency departments (ED) serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland. METHODS: The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital). A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care), B (to be examined within 10 min), C (to be examined within 1 h), D (to be examined within 2 h) and E (no need for immediate treatment) for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse). The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. RESULTS: After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month) as compared to the three previous years in the EDs. The Number of visits to public sector GPs during office hours did not alter. Implementation of ABCDE-triage combined with public guidance was associated with decreased total number of doctor visits in public health care. During same period, the number of patient visits in the private health care increased. Simultaneously, the number of doctor visits in secondary health care ED did not alter. CONCLUSIONS: The present ABCDE-triage system combined with public guidance may reduce patient visits to primary health care EDs but not to the secondary health care EDs. Limiting the access of less urgent patients to ED may redirect the demands of patients to private sector rather than office hours GP services.