scholarly journals Observational study of the implementation of telephone advice nursing in Sweden: did callers follow recommendations and did the rate of healthcare visits change?

BMJ Open ◽  
2021 ◽  
Vol 11 (8) ◽  
pp. e051233
Author(s):  
Amanda Sundberg ◽  
Anna Carin Wahlberg ◽  
Niklas Zethraeus ◽  
Korinna Karampampa
Keyword(s):  
Primary Care ◽  
Observational Study ◽  
Subgroup Analysis ◽  
Secondary Care ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Nursing Service ◽  
Time Period ◽  
Telephone Advice ◽  
Wait And See

ObjectivesTelephone advice nursing is introduced in many countries with one key aim being a reduction of avoidable healthcare visits. The aim of this study was to explore whether callers to a telephone advice nursing service followed the telenurses’ recommendations, and whether there was a change in the level and trend of the rate of healthcare visits after the introduction of telephone advice nursing.DesignObservational study.SettingPrimary and secondary care in Jönköping Region, Sweden.ParticipantsTelephone advice nursing calls, 6:00–23:00, 2014–2015 (n=185 994) and outpatient healthcare visits 2012–2015 (n=6 877 266).Primary outcomeProportion of callers who visited healthcare within the time period advised by the telenurse.Secondary outcomeChange in level or trend of the overall rate of healthcare visits per 1000 persons and 4-week period after the introduction of telephone advice nursing, with subgroup analysis for primary and secondary care.Results77% of callers who were recommended either to visit healthcare within 24 hours or to ‘wait and see’ followed the recommendations. There was no significant change in level (−5.15; 95% CI −15.80 to 5.50; p=0.349) or trend (−0.24; 95% CI −0.86 to 0.38; p=0.448) of the overall rate of visits per 1000 persons and 4-week period after the introduction of telephone advice nursing. For the rate of primary care visits, an increase in level (8.01; 95% CI 6.36 to 9.66; p<0.001) and trend (1.28; 95% CI 1.17 to 1.39; p<0.001) were observed. For the rate of secondary care visits, a decrease in level (−8.77, 95% CI −14.41 to −3.13; p=0.004) and trend (−1.03, 95% CI −1.35 to −0.71; p<0.001) were observed.ConclusionsThe introduction of telephone advice nursing may have contributed to a shift in the rate of healthcare visits from secondary to primary care.

scholarly journals Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care

2020 ◽  
Vol 70 (695) ◽  
pp. e374-e380 ◽  
Author(s):  
Lauren J Scott ◽  
Niamh M Redmond ◽  
Alison Tavaré ◽  
Hannah Little ◽  
Seema Srivastava ◽  
...  
Keyword(s):  
Primary Care ◽  
Observational Study ◽  
Clinical Outcomes ◽  
Early Warning ◽  
Secondary Care ◽  
Early Warning Score ◽  
Medical Review ◽  
News Values ◽  
Process Measures ◽  
Sepsis Diagnosis

BackgroundNHS England has mandated use of the National Early Warning Score (NEWS), more recently NEWS2, in acute settings, and suggested its use in primary care. However, there is reluctance from GPs to adopt NEWS/NEWS2.AimTo assess whether NEWS calculated at the point of GP referral into hospital is associated with outcomes in secondary care.Design and settingAn observational study using routinely collected data from primary and secondary care.MethodNEWS values were prospectively collected for 13 047 GP referrals into acute care between July 2017 and December 2018. NEWS values were examined and multivariate linear and logistic regression used to assess associations with process measures and clinical outcomes.ResultsHigher NEWS values were associated with faster conveyance for patients travelling by ambulance, for example, median 94 minutes (interquartile range [IQR] 69–139) for NEWS ≥7; median 132 minutes, (IQR 84–236) for NEWS = 0 to 2); faster time from hospital arrival to medical review (54 minutes [IQR 25–114] for NEWS ≥7; 78 minutes [IQR 34–158] for NEWS = 0 to 2); as well as increased length of stay (5 days [IQR 2–11] versus 1 day [IQR 0–5]); intensive care unit admissions (2.0% versus 0.5%); sepsis diagnosis (11.7% versus 2.5%); and mortality, for example, 30-day mortality 12.0% versus 4.1% for NEWS ≥7 versus NEWS = 0 to 2, respectively. On average, for patients referred without a NEWS value (NEWS = NR), most clinical outcomes were comparable with patients with NEWS = 3 to 4, but ambulance conveyance time and time to medical review were comparable with patients with NEWS = 0 to 2.ConclusionThis study has demonstrated that higher NEWS values calculated at GP referral into hospital are associated with a faster medical review and poorer clinical outcomes.

scholarly journals Investigation of the demand for a 7-day (extended access) primary care service: an observational study from pilot schemes in England

BMJ Open ◽  
2019 ◽  
Vol 9 (9) ◽  
pp. e028138
Author(s):  
William Whittaker ◽  
Laura Anselmi ◽  
Pauline Nelson ◽  
Caroline O'Donnell ◽  
Natalie Ross ◽  
...  
Keyword(s):  
Primary Care ◽  
Observational Study ◽  
Outcome Measures ◽  
Care Service ◽  
Primary Care Service ◽  
Secondary Outcome ◽  
Family Practitioner ◽  
Spare Capacity ◽  
Patient Demographics ◽  
Extended Access

ObjectivesTo understand how the uptake of an extended primary care service in the evenings and weekend varied by day of week and over time. Secondary objectives were to understand patient demographics of users of the service and how these varied by type of appointment and to core hour users.DesignObservational study.SettingPrimary care extended access appointments data in 13 centres in Greater Manchester, England, during 2016.ParticipantsAppointments could be booked by 1 261 326 patients registered with a family practitioner in five Clinical Commissioning Group geographic areas.Main outcome measuresPrimary outcome measure was whether an appointment was used (booked and attended), secondary outcome measures included whether used appointments were prebooked or booked the same day, and delivered by a family or nurse practitioner. Additional analyses compared patient demographics with patients reporting the use of core hour primary care services.Results65.33% of 42 472 appointments were booked and attended (used). Usage of appointments was lowest on a Sunday at 46.73% (18.07 percentage points lower usage than on Mondays (95% CI −32.46 to −3.68)). Prebooked appointments were less likely to be booked among age group 0–9 and to result in patients not attending an appointment. Family practitioner appointments were increasingly less likely to be booked with age in comparison to nurse appointments. Patients attending extended access appointments tended to be younger in comparison to core hour patients.ConclusionsThere is spare capacity in the extended access service, particularly on Sundays, suggesting reconfigurations of the service may be needed to improve efficiency of delivering the service. Patient demographics suggest the service is used by a relatively younger population than core hour services. Patient demographics varied with the types of appointment provided, these findings may help healthcare providers improve usage by tailoring appointment provision to local populations.

scholarly journals Antifungal prophylaxis for prevention of COVID-19-associated pulmonary aspergillosis in critically ill patients: an observational study

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Stefan Hatzl ◽  
Alexander C. Reisinger ◽  
Florian Posch ◽  
Juergen Prattes ◽  
Martin Stradner ◽  
...  
Keyword(s):  
Observational Study ◽  
Primary Outcome ◽  
Antifungal Prophylaxis ◽  
Secondary Outcome ◽  
Medical Mycology ◽  
Pulmonary Aspergillosis ◽  
Randomized Controlled ◽  
Prophylaxis Group ◽  
Baseline Characteristics ◽  
Propensity Score Adjustment

Abstract Background Coronavirus disease 19 (COVID-19)-associated pulmonary aspergillosis (CAPA) emerged as important fungal complications in patients with COVID-19-associated severe acute respiratory failure (ARF). Whether mould active antifungal prophylaxis (MAFP) can prevent CAPA remains elusive so far. Methods In this observational study, we included all consecutive patients admitted to intensive care units with COVID-19-associated ARF between September 1, 2020, and May 1, 2021. We compared patients with versus without antifungal prophylaxis with respect to CAPA incidence (primary outcome) and mortality (secondary outcome). Propensity score adjustment was performed to account for any imbalances in baseline characteristics. CAPA cases were classified according to European Confederation of Medical Mycology (ECMM)/International Society of Human and Animal Mycoses (ISHAM) consensus criteria. Results We included 132 patients, of whom 75 (57%) received antifungal prophylaxis (98% posaconazole). Ten CAPA cases were diagnosed, after a median of 6 days following ICU admission. Of those, 9 CAPA cases were recorded in the non-prophylaxis group and one in the prophylaxis group, respectively. However, no difference in 30-day ICU mortality could be observed. Thirty-day CAPA incidence estimates were 1.4% (95% CI 0.2–9.7) in the MAFP group and 17.5% (95% CI 9.6–31.4) in the group without MAFP (p = 0.002). The respective subdistributional hazard ratio (sHR) for CAPA incidence comparing the MAFP versus no MAFP group was of 0.08 (95% CI 0.01–0.63; p = 0.017). Conclusion In ICU patients with COVID-19 ARF, antifungal prophylaxis was associated with significantly reduced CAPA incidence, but this did not translate into improved survival. Randomized controlled trials are warranted to evaluate the efficacy and safety of MAFP with respect to CAPA incidence and clinical outcomes.

scholarly journals Association between potentially inappropriate medications at discharge and unplanned readmissions among hospitalised elderly patients at a single centre in Japan: a prospective observational study

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e032574 ◽  
Author(s):  
Junpei Komagamine ◽  
Taku Yabuki ◽  
Masaki Kobayashi
Keyword(s):  
Observational Study ◽  
Elderly Patients ◽  
Prospective Observational Study ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Unplanned Readmission ◽  
Potentially Inappropriate Medications ◽  
Patient Age ◽  
Patient Âgé ◽  
Increased Risk

ObjectiveTo determine the prevalence of potentially inappropriate medication (PIM) use at admission and discharge among hospitalised elderly patients and evaluate the association between PIMs at discharge and unplanned readmission in Japan.DesignA prospective observational study conducted by using electronic medical records.ParticipantsAll consecutive patients aged 65 years or older who were admitted to the internal medicine ward were included. Patients who were electively admitted for diagnostic procedures were excluded.Main outcome measuresThe primary outcome was 30-day unplanned readmissions. The secondary outcome was the prevalence of any PIM use at admission and discharge. PIMs were defined based on the Beers Criteria. The association between any PIM use at discharge and the primary outcome was evaluated by using logistic regression.ResultsSeven hundred thirty-nine eligible patients were included in this study. The median patient age was 82 years (IQR 74–88); 389 (52.6%) were women, and the median Charlson Comorbidity Index was 2 (IQR 0–3). The proportions of patients taking any PIMs at admission and discharge were 47.2% and 32.2%, respectively. Of all the patients, 39 (5.3%) were readmitted within 30 days after discharge for the index hospitalisation. The use of PIMs at discharge was not associated with an increased risk of 30-day readmission (OR 0.93; 95% CI 0.46 to 1.87). This result did not change after adjusting for patient age, sex, number of medications, duration of hospital stay and comorbidities (OR 0.78; 95% CI 0.36 to 1.66).ConclusionThe prevalence of any PIM use at discharge was high among hospitalised elderly patients in a Japanese hospital. Although the use of PIMs at discharge was not associated with an increased risk of unplanned readmission, given a lack of power of this study due to a low event rate, further studies investigating this association are needed.Trial registration numberUMIN000027189.

scholarly journals Influence of overstated abstract conclusions on clinicians: a web-based randomised controlled trial

BMJ Open ◽  
2017 ◽  
Vol 7 (12) ◽  
pp. e018355 ◽  
Author(s):  
Kiyomi Shinohara ◽  
Takuya Aoki ◽  
Ryuhei So ◽  
Yasushi Tsujimoto ◽  
Aya M Suganuma ◽  
...  
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Primary Outcome ◽  
Controlled Trial ◽  
Mean Difference ◽  
Secondary Outcome ◽  
Outcome Information ◽  
Significant Difference ◽  
Registration Number ◽  
Randomised Controlled

ObjectivesTo investigate whether overstatements in abstract conclusions influence primary care physicians’ evaluations when they read reports of randomised controlled trials (RCTs)DesignRCT setting: This study was a parallel-group randomised controlled survey, conducted online while masking the study hypothesis.ParticipantsVolunteers were recruited from members of the Japan Primary Care Association in January 2017. We sent email invitations to 7040 primary care physicians. Among the 787 individuals who accessed the website, 622 were eligible and automatically randomised into ‘without overstatement’ (n=307) and ‘with overstatement’ (n=315) groups.InterventionsWe selected five abstracts from published RCTs with at least one non-significant primary outcome and overstatement in the abstract conclusion. To construct a version without overstatement, we rewrote the conclusion sections. The methods and results sections were standardised to provide the necessary information of primary outcome information when it was missing in the original abstract. Participants were randomly assigned to read an abstract either with or without overstatements and asked to evaluate the benefit of the intervention.Outcome measuresThe primary outcome was the participants’ evaluation of the benefit of the intervention discussed in the abstract, on a scale from 0 to 10. A secondary outcome was the validity of the conclusion.ResultsThere was no significant difference between the groups with respect to their evaluation of the benefit of the intervention (mean difference: 0.07, 95% CI −0.28 to 0.42, p=0.69). Participants in the ‘without’ group considered the study conclusion to be more valid than those in the ‘with’ group (mean difference: 0.97, 95% CI 0.59 to 1.36, P<0.001).ConclusionThe overstatements in abstract conclusions did not significantly influence the primary care physicians’ evaluations of the intervention effect when necessary information about the primary outcomes was distinctly reported.Trial registration numberUMIN000025317; Pre-results.

scholarly journals Route to diagnosis of degenerative cervical myelopathy in a UK healthcare system: a retrospective cohort study

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e027000 ◽  
Author(s):  
Bryn Hilton ◽  
Jennifer Tempest-Mitchell ◽  
Benjamin Davies ◽  
Mark Kotter
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Symptom Onset ◽  
Cervical Myelopathy ◽  
Secondary Care ◽  
Primary Outcome ◽  
Cord Compression ◽  
Cervical Cord ◽  
Clinical Documentation ◽  
Degenerative Cervical Myelopathy

ObjectivesDegenerative cervical myelopathy (DCM) presents insidiously, making initial diagnosis challenging. Surgery has been shown to prevent further disability but existing spinal cord damage may be permanent. Delays in surgery lead to increased disability and reduced postoperative improvements. Therefore, rapid surgical assessment is key to improving patient outcomes. Unfortunately, diagnosis of DCM in primary care is often delayed. This study aimed to characterise patients with DCM route to diagnosis and surgical assessment as well as to plot disease progression over time.DesignRetrospective, observational cohort study.SettingSingle, tertiary centre using additional clinical records from primary and secondary care centres.ParticipantsOne year of cervical MRI scans conducted at a tertiary neurosciences centre (n=1123) were screened for cervical cord compression, a corresponding clinical diagnosis of myelopathy and sufficient clinical documentation to plot a route to diagnosis (n=43).Primary outcome measuresTime to diagnosis from symptom onset, route to diagnosis and disease progression were the primary outcome measures in this study. Disease severity was approximated using a prospectively validated method for inferring modified Japanese Orthopaedic Association (i-mJOA) functional scoring from clinical documentation.ResultsPatients received a referral to secondary care 6.4±7.7 months after symptom onset. Cervical MRI scanning and neurosurgical review occurred 12.5±13.0 and 15.8±13.5 months after symptom onset, respectively. i-mJOA was 16.0±1.7 at primary care assessment and 14.8±2.5 at surgical assessment. 61.0% of patients were offered operations. For those who received surgery, time between onset and surgery was 22.1±13.2 months.ConclusionsRoute to surgical assessment was heterogeneous and lengthy. Some patients deteriorated during this period. This study highlights the need for a streamlined pathway by which patients with cervical cord compression can receive timely assessment and treatment by a specialist. This would improve outcomes for patients using existing treatments.

scholarly journals Referrals to secondary care in an outpatient primary care walk-in clinic for refugees in Germany: results from a secondary data analysis based on electronic medical records

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e035625
Author(s):  
Ingmar Schäfer ◽  
Jan Hendrik Oltrogge ◽  
Susanne Pruskil ◽  
Claudia Mews ◽  
Dana Schlichting ◽  
...  
Keyword(s):  
Primary Care ◽  
Secondary Care ◽  
Cox Regression ◽  
Country Of Origin ◽  
Secondary Data ◽  
Routine Data ◽  
Health Problems ◽  
Secondary Outcome ◽  
Data Set ◽  
Healthcare Needs

ObjectivesThe aims of our study were to describe the disease spectrum of refugees, to analyse to what extent their healthcare needs could be met in an outpatient primary care walk-in clinic and which cases required additional services from secondary care (ie, outpatient specialists or hospitals).DesignRetrospective longitudinal observational study.SettingThe study was based on routine data from a walk-in clinic in the largest central first reception centre in Hamburg, Germany between 4 November 2015 and 21 July 2016.Participants1467 asylum seekers with 4006 episodes of care (ie, distinctive health problems) resulting in 5545 consultations. The patients were 60% men and had a mean age of 23.2 years. About 90% of the patients were from Central Asia or from the Middle East and North Africa.Primary and secondary outcome measuresThe endpoint of our analyses was referral to secondary care. Time to event was defined as days under treatment until the first referral. Predictor variables were the patients’ diagnoses grouped in 46 categories. The data set was analysed by Cox regression allowing for multiple failure times per patient. This analysis was adjusted for age, sex and country of origin.ResultsReferrals to secondary care occurred in 15.5% of the episodes. The diagnosis groups with the highest referral rates were ‘eye’ (HR 4.9; 95% CI 3.12 to 7.8; p≤0.001), ‘teeth/gum symptom/complaint or disease’ (3.51; 2.52 to 4.9; p≤0.001) and ‘urological system/female or male genital’ (2.50; 1.66 to 3.77; p≤0.001). Age, sex and country of origin had no significant effect on time until referral.ConclusionsIn most cases, the walk-in clinic physicians could provide first-line medical care for the health problems of patients not integrated in the German healthcare system. Additional resources were needed particularly not only for visual impairment and dental problems but also for psychological disorders, antenatal care and certain infections and injuries.

scholarly journals Psychosomatic therapy for patients frequently attending primary care with medically unexplained symptoms, the CORPUS trial: study protocol for a randomised controlled trial

Trials ◽  
2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Margreet S. H. Wortman ◽  
Johannes C. van der Wouden ◽  
Janneke P. C. Grutters ◽  
Bart Visser ◽  
Willem J. J. Assendelft ◽  
...  
Keyword(s):  
Primary Care ◽  
Economic Evaluation ◽  
Usual Care ◽  
Secondary Care ◽  
Outcome Measure ◽  
Medically Unexplained Symptoms ◽  
Secondary Outcome ◽  
Patient Specific ◽  
Medically Unexplained ◽  
Unexplained Symptoms

Abstract Background Medically unexplained symptoms (MUS) are highly prevalent and pose a burden both on patients and on health care. In a pilot study psychosomatic therapy delivered by specialised therapists for patients with MUS showed promising results with regard to patient’s acceptability, feasibility and effects on symptoms. The aim of this study is to establish whether psychosomatic therapy by specialised psychosomatic exercise therapists is cost- effective in decreasing symptoms and improving functioning in patients who frequently consult their general practitioner (GP) with MUS. Methods A randomised effectiveness trial with an economic evaluation in primary care with 158 patients aged 18 years and older who are frequently consulting their GP with MUS. Patients will be assigned to psychosomatic therapy in addition to usual care or usual care only. Psychosomatic therapy is a multi-component and tailored intervention, aiming to empower patients by applying psycho-education, relaxation techniques, mindfulness, cognitive approaches and/or graded activity. Patients assigned to the psychosomatic therapy receive 6 to 12 sessions of psychosomatic therapy, of 30–45 min each, delivered by a specialised exercise or physical therapist. Primary outcome measure is patient-specific functioning and disability, measured with the Patient-Specific Functional Scale (PSFS). Secondary outcome measures are symptom severity, consultation frequency and referrals to secondary care, patient satisfaction, quality of life and costs. Assessments will be carried out at baseline, and after 4 and 12 months. An economic evaluation alongside the trial will be conducted from a societal perspective, with quality-adjusted life years (QALYs) as outcome measure. Furthermore, a mixed-methods process evaluation will be conducted. Discussion We expect that psychosomatic therapy in primary care for patients who frequently attend the GP for MUS will improve symptoms and daily functioning and disability, while reducing consultation frequency and referrals to secondary care. We expect that the psychosomatic therapy provides value for money for patients with MUS. Trial registration Netherlands Trial Register, ID: NL7157 (NTR7356). Registered 13 July 2018.

scholarly journals Triaging and Referring In Adjacent General and Emergency Departments (the TRIAGE trial): a cluster randomised controlled trial

2021 ◽  
Author(s):  
Stefan Morreel ◽  
Hilde Philips ◽  
Diana De Graeve ◽  
Koenraad G Monsieurs ◽  
Jarl Kampen ◽  
...  
Keyword(s):  
Primary Care ◽  
Randomised Controlled Trial ◽  
Primary Outcome ◽  
Controlled Trial ◽  
Intervention Group ◽  
Cluster Randomised Controlled Trial ◽  
Secondary Outcome ◽  
Control Group ◽  
Predictive Values ◽  
Randomised Controlled

Objectives: To determine the effectiveness and safety of a tool diverting low urgency patients eligible for primary care from an emergency department (ED) to the adjacent general practitioner cooperative (GPC). Methods: Unblinded, randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was nurse-led triage using a new tool assigning patients to either ED or GPC. During intervention weekends, patients were encouraged to follow this assignment while it was not communicated to the patients during control weekends (they remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC during intervention and control weekends. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care eligible patients (with the opinion of the treating physician as the gold standard). Results: In the intervention group, 838/6374 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC (secondary outcome), in the control group 431/1744 (24.7%, 95% CI 22.7 to 26.8). In the intervention group, 599/6374 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the chosen MTS presentational flowchart, patient's age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) patients were referred back to the ED of which three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised. Conclusions: ED nurses using a new tool safely diverted 9.5% of the included patients to primary care. ClinicalTrials.gov Identifier: NCT03793972 Funding: Research Foundation, Flanders (FWO)

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