High referral rates to secondary care by general practitioners in Norway are associated with GPs' gender and specialist qualifications in family medicine, a study of 4350 consultations

This article is part of Unni Ringberg's doctoral thesis which is available in Munin at http://hdl.handle.net/10037/7607Referral rates of general practitioners (GPs) are an important determinant of secondary care utilization. The variation in these rates across GPs is considerable, and cannot be explained by patient morbidity alone. The main objective of this study was to assess the GPs’ referral rate to secondary care in Norway, any associations between the referral decision and patient, GP, health care characteristics and who initiated the referring issue in the consultation. The probabilities of referral to secondary care and/or radiological examination were examined in 100 consecutive consultations of 44 randomly chosen Norwegian GPs. The GPs recorded whether the issue of referral was introduced, who introduced it and if the patient was referred. Multilevel and naive multivariable logistic regression analyses were performed to explore associations between the probability of referral and patient, GP and health care characteristics. Of the 4350 consultations included, 13.7% (GP range 4.0%-28.0%) of patients were referred to secondary somatic and psychiatric care. Female GPs referred significantly more frequently than male GPs (16.0% versus 12.6%, adjusted odds ratio, AOR, 1.25), specialists in family medicine less frequently than their counterparts (12.5% versus 14.9%, AOR 0.76) and salaried GPs more frequently than private practitioners (16.2% versus 12.1%, AOR 1.36). In 4.2% (GP range 0%-12.9%) of the consultations, patients were referred to radiological examination. Specialists in family medicine, salaried GPs and GPs with a Norwegian medical degree referred significantly more frequently to radiological examination than their counterparts (AOR 1.93, 2.00 and 1.73, respectively). The issue of referral was introduced in 23% of the consultations, and in 70.6% of these cases by the GP. The high referrers introduced the referral issue significantly more frequently and also referred a significantly larger proportion when the issue was introduced. The main finding of the present study was a high overall referral rate, and a striking range among the GPs. Male GPs and specialists in family medicine referred significantly less frequently to secondary care, but the latter referred more frequently to radiological examination. Our findings indicate that intervention on high referrers is a potential area for quality improvement, and there is a need to explore the referral decision process itself

Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial

Objective To assess the efficacy of caudal epidural steroid or saline injection in chronic lumbar radiculopathy in the short (6 weeks), intermediate (12 weeks), and long term (52 weeks). Design Multicentre, blinded, randomised controlled trial. Setting Outpatient multidisciplinary back clinics of five Norwegian hospitals. Participants Between October 2005 and February 2009, 461 patients assessed for inclusion (presenting with lumbar radiculopathy >12 weeks). 328 patients excluded for cauda equina syndrome, severe paresis, severe pain, previous spinal injection or surgery, deformity, pregnancy, ongoing breast feeding, warfarin therapy, ongoing treatment with non-steroidal anti-inflammatory drugs, body mass index >30, poorly controlled psychiatric conditions with possible secondary gain, and severe comorbidity. Interventions Subcutaneous sham injections of 2 mL 0.9% saline, caudal epidural injections of 30 mL 0.9% saline, and caudal epidural injections of 40 mg triamcinolone acetonide in 29 mL 0.9% saline. Participants received two injections with a two week interval. Main outcome measures Primary: Oswestry disability index scores. Secondary: European quality of life measure, visual analogue scale scores for low back pain and for leg pain. Results Power calculations required the inclusion of 41 patients per group. We did not allocate 17 of 133 eligible patients because their symptoms improved before randomisation. All groups improved after the interventions, but we found no statistical or clinical differences between the groups over time. For the sham group (n=40), estimated change in the Oswestry disability index from the adjusted baseline value was −4.7 (95% confidence intervals −0.6 to −8.8) at 6 weeks, −11.4 (−6.3 to −14.5) at 12 weeks, and −14.3 (−10.0 to −18.7) at 52 weeks. For the epidural saline intervention group (n=39) compared with the sham group, differences in primary outcome were −0.5 (−6.3 to 5.4) at 6 weeks, 1.4 (−4.5 to 7.2) at 12 weeks, and −1.9 (−8.0 to 4.3) at 52 weeks; for the epidural steroid group (n=37), corresponding differences were −2.9 (−8.7 to 3.0), 4.0 (−1.9 to 9.9), and 1.9 (−4.2 to 8.0). Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. Conclusions Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy

Does long-term care use within primary health care reduce hospital use among older people in Norway? A national five-year population-based observational study

<p>Abstract</p> <p>Background</p> <p>Population ageing may threaten the sustainability of future health care systems. Strengthening primary health care, including long-term care, is one of several measures being taken to handle future health care needs and budgets. There is limited and inconsistent evidence on the effect of long-term care on hospital use. We explored the relationship between the total use of long-term care within public primary health care in Norway and the use of hospital beds when adjusting for various effect modifiers and confounders.</p> <p>Methods</p> <p>This national population-based observational study consists of all Norwegians (59% women) older than 66 years (N = 605676) (13.2% of total population) in 2002-2006. The unit of analysis was defined by municipality, age and sex. The association between total number of recipients of long-term care per 1000 inhabitants (LTC-rate) and hospital days per 1000 inhabitants (HD-rate) was analysed in a linear regression model. Modifying and confounding effects of socioeconomic, demographic and geographic variables were included in the final model. We defined a difference in hospitalization rates of more than 1000 days per 1000 inhabitants as clinically important.</p> <p>Results</p> <p>Thirty-one percent of women and eighteen percent of men were long-term care users. Men had higher HD-rates than women. The crude association between LTC-rate and HD-rate was weakly negative. We identified two effect modifiers (age and sex) and two strong confounders (travel time to hospital and mortality). Age and sex stratification and adjustments for confounders revealed a positive statistically significant but not clinically important relationship between LTC-rates and hospitalization for women aged 67-79 years and all men. For women 80 years and over there was a weak but negative relationship which was neither statistically significant nor clinically important.</p> <p>Conclusions</p> <p>We found a weak positive adjusted association between LTC-rates and HD-rates. Opposite to common belief, we found that increased volume of LTC by itself did not reduce pressure on hospitals. There still is a need to study integrated care models for the elderly in the Norwegian setting and to explore further why municipalities far away from hospital achieve lower use of hospital beds.</p

The european primary care monitor: structure, process and outcome indicators

<p>Abstract</p> <p>Background</p> <p>Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.</p> <p>There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care.</p> <p>Methods</p> <p>A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems).</p> <p>Results</p> <p>The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care.</p> <p>Conclusions</p> <p>A standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.</p

Head, Neck and Shoulder Pain. A study of the Population and of Patients of General Practitioners, 1990

An analysis of the association between muscle and skeletal issues and "well-being factor" has been conducted. The project includes a cross-sectional survey of all people living in Bardu municipality between the ages 20-70, net sample: 1938 respondents

Headache and neck or shoulderpain. An analysis of musculoskeletal problems in three comprehensive population studies in Northern Norway.

Papers in this thesis:I: B. K. Jacobsena1 c1, T. Hasvolda1, G. Høyera1 and V. Hansen: ‘The General Health Questionnaire: how many items are really necessary in population surveys?’. Psychological Medicine, Volume 25, Issue 05, September 1995, pp 957-961 (http://dx.doi.org/10.1017/S0033291700037442)II: Toralf Hasvold, and Roar Johnsen: ‘Headache and neck or shoulder pain - frequent and disabling complaints in the general population’. Scandinavian Journal of Primary Health Care, 1993, Vol. 11, No. 3, Pages 219-224.III: Toralf Hasvold and Roar Johnsen: ‘Headache and neck or shoulder pain—family learnt illnesses behaviour? The Bardu Muscoloskeletal Study, 1989–1990’. Family Practice (1996) 13 (3): 242-246 (http://dx.doi.org/10.1093/fampra/13.3.242) IV: Toralf Hasvold, Roar Johnsen, Olav Helge Førde: ‘Non-migrainous headache, neck or shoulder pain, and migraine — differences in association with background factors in a city population’. Scandinavian Journal of Primary Health Care Jan 1996, Vol. 14, No. 2: 92–99.V: Toralf Hasvold, Roar Johnsen, Olav Helge Førde: ‘Musculoskeletal problems- result of “mental pain” rather than physical strain?. (Manuscript)

Forty years of allocated seats for Sami medical students : has preferential admission worked?

This article examines the effects of a special admission policy for Sami medical students in Norway. In the 1960s, public health and health care were found to be poorer in Sami communities than in the rest of Norway. There were few doctors and none of them spoke Sami. Sami school leavers found it difficult to gain admittance to medical schools. In response to this situation, the medical faculty at the University of Bergen adopted a special admissions policy for Sami students in 1963. The University of Tromsø did the same in 1991. In this study we have analyzed whether the allocated Sami seats produced the desired outcomes. In assessing the outcomes, the study takes into account the considerable improvements in public health and health care in the last 40 years, wider use of the Sami language and generally higher educational achievements among the Sami. This retrospective study was set in two medical schools in Norway. The study population is students admitted to medical school on allocated Sami seats, in the two periods 1963-1986 at the University of Bergen, and 1991-2000 at the University of Tromsø. After a question identified the Sami students, whether they had practised or were practising medicine was determined. In total 38 students were admitted on the allocated Sami seats, and 32 graduated. Of the candidates, 93% had practised medicine in one of the two northernmost counties in Norway. Graduates during the 1960s and 1970s were more likely to have worked as GPs in the main areas of Sami habitation than the Sami physicians who graduated later. The Sami doctors admitted to medical school on allocated Sami seats have practiced in Finnmark or Troms, counties where most of the Sami people live. However, this study was unable to establish whether admission on these grounds led to more Sami doctors working in the main areas of Sami habitation. Regarding the workplace location variable, there were no differences between Sami and other physicians from the northern part of Norway who were educated at the University of Tromsø

The delivery of primary care services

This chapter will be devoted to the dimensions which have been grouped in the framework as “process” and that focus on essential features of service delivery in primary care. In addition to the breadth of services delivered, a comparative overview will be provided of variation in access to services, and continuity and coordination of care. In addition to the volume and type of primary care services, accessibility is determined by the remoteness of services and the practice organization (e.g. appointment system, after-hours care arrangements, (home visits). Financial barriers, such as co-payments, determine the financial accessibility of primary care. The extent to which access to primary care services is provided on the basis of health needs, without systematic differences on the basis of individual or social characteristics, indicates the level of equality in access that is achieved. Continuity of care comprises relationship and management continuity. The coordination function reflects the ability of primary care providers to coordinate use of services within primary care and in other levels of health care. It is determined by the presence of a gatekeeping system, practice structure and teamwork, diversification and substitution of primary care providers, and integration and collaboration of primary care with secondary care and the public health sector. This chapter will conclude with a mapping exercise of the breadth of services delivered, accessibility, continuity and coordination of care in countries across Europe, showing also the interrelations across dimensions. (aut. ref.

Is a high level of general practitioner consultations associated with low outpatients specialist clinic use? A cross-sectional study

Objective: To examine if increased general practice activity is associated with lower outpatient specialist clinic use. Design: Cross-sectional population based study. Setting: All 430 Norwegian municipalities in 2009. Participants: All Norwegians aged ≥65 years (n=721 915; 56% women—15% of the total population). Main outcome measure: Specialised care outpatient clinic consultations per 1000 inhabitants (OPC rate). Main explanatory: general practitioner (GP) consultations per 1000 inhabitants (GP rate). Results: In total, there were 3 339 031 GP consultations (57% women) and 1 757 864 OPC consultations (53% women). The national mean GP rate was 4625.2 GP consultations per 1000 inhabitants (SD 1234.3) and the national mean OPC rate was 2434.3 per 1000 inhabitants (SD 695.3). Crude analysis showed a statistically significant positive association between GP rates and OPC rates. In regression analyses, we identified three effect modifiers; age, mortality and the municipal composite variable of ‘hospital status’ (present/not present) and ‘population size’ (small, medium and large). We stratified manually by these effect modifiers into five strata. Crude stratified analyses showed a statistically significant positive association for three out of five strata. For the same three strata, those in the highest GP consultation rate quintile had higher mean OPC rates compared with those in the lowest quintile after adjustment for confounders (p<0.001). People aged ≥85 in small municipalities had approximately 30% lower specialist care use compared with their peers in larger municipalities, although the association between GP-rates and OPC-rates was still positive. Conclusions: In a universal health insurance system with high GP-accessibility, a health policy focusing solely on a higher activity in terms of GP consultations will not likely decrease OPC use among elderly