BACKGROUND: A severely injured patient needs fast transportation to a hospital that can provide definitive care. In Norway, approximately 20% of the population live in rural areas. Primary care doctors (PCDs) play an important role in prehospital trauma care. The aim of this study was to investigate how variations in PCD call-outs to severe trauma incidents in Norway were associated with rural-urban settings and time factors.
METHODS: In this study on severe trauma patients admitted to Norwegian hospitals from 2012 to 2018, we linked data from four official Norwegian registries. Through this, we investigated the call-out responses of PCDs to severe trauma incidents. In multivariable log-binomial regression models, we investigated whether factors related to rural-urban settings and time factors were associated with PCD call-outs.
RESULTS: There was a significantly higher probability of PCD call-outs to severe trauma incidents in the municipalities in the four most rural centrality categories compared to the most urban category. The largest difference in adjusted relative risk (95% confidence interval (CI)) was 2.08 (1.27-3.41) for centrality category four. PCDs had a significantly higher proportion of call-outs in the Western (RR = 1.46 (1.23-1.73)) and Central Norway (RR = 1.30 (1.08-1.58)) Regional Health Authority areas compared to in the South-Eastern area. We observed a large variation (0.47 to 4.71) in call-out rates to severe trauma incidents per 100,000 inhabitants per year across the 16 Emergency Medical Communication Centre areas in Norway.
CONCLUSIONS: Centrality affects the proportion of PCD call-outs to severe trauma incidents, and call-out rates were higher in rural than in urban areas. We found no significant difference in call-out rates according to time factors. Possible consequences of these findings should be further investigated.

BACKGROUND: Telephone triage is used to optimise patient flow in emergency primary healthcare. Poor communication can lead to misunderstandings and compromise patient safety. To improve quality, a comprehensive understanding of factors affecting communication in medical call centres in primary care is needed. The aim of this review was to identify such factors and to describe how they affect communication during telephone triage.
METHODS: A mixed-method systematic review was performed. In April 2021 and June 2023, MEDLINE, Embase, CINAHL, and Web of Science were searched for original studies describing communication during telephone triage in primary care medical call centres handling all types of medical problems from an unselected population. All studies were screened by two authors, blinded to each other\'s decisions. Disagreements were resolved by a third author. A framework was created by the thematic synthesis of the qualitative data and later used to synthesise the quantitative data. By using convergent integrated synthesis, the qualitative and quantitative findings were integrated. The Mixed Methods Appraisal Tool was used to assess methodological limitations.
RESULTS: Out of 5087 studies identified in the search, 62 studies were included, comprising 40 qualitative, 16 quantitative and six mixed-method studies. Thirteen factors were identified and organised into four main themes: organisational factors, factors related to the operator, factors related to the caller and factors in the interaction. Organisational factors included availability, working conditions and decision support systems. Factors related to the operator were knowledge and experience, personal qualities and communication strategies. Factors related to the caller were individual differences and the presented medical problem. Factors in the interaction were faceless communication, connection between operator and caller, third-person caller and communication barriers. The factors seem interrelated, with organisational factors affecting all parts of the conversation, and the operator\'s communication in particular.
CONCLUSIONS: Many factors affect the structure, content, and flow of the conversation. The operators influence the communication directly but rely on the organisation to create a working environment that facilitates good communication. The results are mainly supported by qualitative studies and further studies are needed to explore and substantiate the relevance and effect of individual factors.
BACKGROUND: PROSPERO CRD42022298022.

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.
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.
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.
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.

UNASSIGNED: Healthcare usage patterns change for people with life limiting illness as death approaches, with increasing use of out-of-hours services. How best to provide care out of hours is unclear.
UNASSIGNED: To evaluate the effectiveness and effect of enhancements to 7-day specialist palliative care services, and to explore a range of perspectives on these enhanced services.
UNASSIGNED: An exploratory longitudinal mixed-methods convergent design. This incorporated a quasi-experimental uncontrolled pre-post study using routine data, followed by semi-structured interviews with patients, family carers and health care professionals.
UNASSIGNED: Data were collected within specialist palliative care services across two UK localities between 2018 and 2020. Routine data from 5601 unique individuals were analysed, with post-intervention interview data from patients (n = 19), family carers (n = 23) and health care professionals (n = 33; n = 33 time 1, n = 20 time 2).
UNASSIGNED: The mean age of people receiving care was 73 years, predominantly white (90%) and with cancer (42%). There were trends for those in the intervention (enhanced care) period to stay in hospital 0.16 days fewer, but be hospitalised 2.67 more times. Females stayed almost 3.5 more days in the hospital, but were admitted 2.48 fewer times. People with cancer had shorter hospitalisations (4 days fewer), and had two fewer admission episodes. Themes from the qualitative data included responsiveness (of the service); reassurance; relationships; reciprocity (between patients, family carers and staff) and retention (of service staff).
UNASSIGNED: Enhanced seven-day services provide high quality integrated palliative care, with positive experiences for patients, carers and staff.

UNASSIGNED: To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT).
UNASSIGNED: A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018.
UNASSIGNED: All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period.
UNASSIGNED: We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use.
UNASSIGNED: Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40-59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0-19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing.
UNASSIGNED: The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40-59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

Background: Survey studies suggest that COVID-19 has had a negative impact on the population\'s mental well-being. Routine registration data allow a more objective way for investigating such associations, complementary to self-report measures. This study investigates the level of out of hours (OOH) consultations for psychological problems since the start of the COVID-19 pandemic in Flanders, Belgium. Methods: The iCAREdata database is a clinical research database with routine data of OOH care, covering a large area in Flanders, Belgium. After defining the first wave and the second wave of COVID-19 in Flanders in time, we compared the number of consultations regarding psychological problems (in general, anxiety-related, depression-related, and sleep-related) between those periods, the period in between these waves, and the period before the start of COVID-19. Results: A significant rise in OOH consultations due to psychological-and more specifically, anxiety-related-problems is observed since the start of the COVID-19 pandemic in Flanders. Elevated levels are observed until the second wave. This finding is in sharp contrast with the general pattern of lower demand for primary healthcare during this period. The majority of these supplementary consultations happened by phone. Consultations regarding depression-related problems did not change over time. Sleep disturbances in the OOH setting were more common after the first wave. Conclusion: Despite some limitations, a large Flemish database with routine data on OOH care shows an increase in the number of consultations regarding psychological problems in general and anxiety-related problems since the start of the COVID-19-pandemic until the second wave.

Deaths in the community are increasing. However, community palliative care out-of-hours is variable. We lack detailed understanding of how care is provided out-of-hours and the associated outcomes.
To review systematically the components, outcomes and economic evaluation of community-based \'out-of-hours\' care for patients near the end of life and their families.
Mixed method systematic narrative review. Narrative synthesis, development and application of a typology to categorise out-of-hours provision. Qualitative data were synthesised thematically and integrated at the level of interpretation and reporting.
Systematic review searching; MEDLINE, EMBASE, PsycINFO, CINAHL from January 1990 to 1st August 2022.
About 64 publications from 54 studies were synthesised (from 9259 retrieved). Two main themes were identified: (1) importance of being known to a service and (2) high-quality coordination of care. A typology of out-of-hours service provision was constructed using three overarching dimensions (service times, focus of team delivering the care and type of care delivered) resulting in 15 categories of care. Only nine papers were randomised control trials or controlled cohorts reporting outcomes. Evidence on effectiveness was apparent for providing 24/7 specialist palliative care with both hands-on clinical care and advisory care. Only nine publications reported economic evaluation.
The typological framework allows models of out-of-hours care to be systematically defined and compared. We highlight the models of out-of-hours care which are linked with improvement of patient outcomes. There is a need for effectiveness and cost effectiveness studies which define and categorise out-of-hours care to allow thorough evaluation of services.

In a gatekeeping system, the individual doctor\'s referral practice is an important factor for hospital activity and patient safety.
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.
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.
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.
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.

BACKGROUND: Primary care is the first point of contact for all acute health problems. As such, primary care was at the frontline in the COVID-19 pandemic, playing a significant role in clinical responses and information to the public. This study aimed to describe the variations in patient management strategies used in the out-of-hours services in different European countries during the first phase of the pandemic.
METHODS: We conducted a cross-sectional web-based survey in August 2020, selecting key informants from European countries using European networks. The questionnaire was developed in collaboration with researchers in the field of out-of-hours primary care. We performed descriptive analyses per region, structuring results into themes.
RESULTS: Key informants from 38 regions in 20 European countries responded. Seven regions reported that their out-of-hours services had a pandemic preparedness plan, three had trained on the plan, and two had stockpiles of personal protection equipment before the outbreak. Extension of telephone triage lines and establishment of local infection-control teams and clinics were the main patient management strategies. Other strategies for patient contacts were also used in the regions, such as video-consultations (13 regions), electronic consultations (21 regions), patient\'s car as alternative waiting room (19 regions), outside tents for testing (24 regions), \"drive-through\" testing (26 regions), and separate departments for infected patients (14 regions).
CONCLUSIONS: Few out-of-hours services were well prepared for a pandemic, but all expanded and reorganized rapidly, adopting new strategies for patient management and treatment. The results could be useful for planning of organization preparedness of out-of-hours primary care service for future pandemics.

UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: OOH primary care of the Central Denmark Region.
UNASSIGNED: All patient contacts in 2014-2017.
UNASSIGNED: GPs\' tendency to prescribe antibiotics. Excess variation (not attributable to chance).
UNASSIGNED: 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).
UNASSIGNED: 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.