The Impact of a Primary Care Physician Cooperative on the Caseload of an
Emergency Department: The Maastricht Integrated Out-of-Hours Service
Caro J.T. van Uden, MSc,
Ron A.G. Winkens, MD, PhD,
Geertjan Wesseling, MD, PhD,
Hans F.B.M. Fiolet, MD, PhD,
Onno C.P. van Schayck, PhD,
Harry F.J.M. Crebolder, MD, PhD
Department of Integrated Care, Research Institute Caphri, University Hospital Maastricht, Maastricht, The Netherlands;
General Practice, Research Institute Caphri, Maastricht University, Maastricht, The Netherlands;
Department of Respiratory Diseases,
Research Institute Caphri, University Hospital Maastricht, Maastricht, The Netherlands.
OBJECTIVE: To determine the effect of an out-of-hours primary care
physician (PCP) cooperative on the caseload at the emergency depart-
ment (ED) and to study characteristics of patients utilizing out-of-
DESIGN: A pre–post intervention design was used. During a 3-week
period before and a 3-week period after establishing the PCP coopera-
tive, all patient records with out-of-hours primary and emergency care
SETTING: Primary care in Maastricht (the Netherlands) is delivered by
59 PCPs. Primary care physicians formerly organized out-of-hours care
in small locum groups. In January 2000, out-of-hours primary care
was reorganized, and a PCP cooperative was established. This coopera-
tive is located at the ED of the University Hospital Maastricht, the city’s
only hospital, which has no emergency medicine specialists.
MAIN OUTCOME MEASURES: The number of patients utilizing out-of-
hours care, their age and sex, diagnoses, post-ED care, and serious
RESULTS. After establishing the PCP cooperative, the proportion of
patients utilizing emergency care decreased by 53%, and the proportion
of patients utilizing primary care increased by 25%. The shift was the
largest for patients with musculoskeletal disorders or skin problems.
There were fewer hospital admissions, and fewer subsequent referrals
to the patient’s own PCP and medical specialists. No substantial change
in new outpatient visits at the hospital or in mortality occurred.
CONCLUSIONS: In the city of Maastricht, the Netherlands, the PCP
cooperative reduced the use of hospital emergency care during out-of-
KEY WORDS: primary care; emergency medicine; gatekeeping; after-
J GEN INTERN MED 2005; 20:612–617.
rimary care gatekeeping in the Netherlands, as in the
is less controversial than in the United States.
Whereas in the United States only about 40% of the population
has a primary care physician (PCP) who acts as a gatekeeper to
in the Dutch health care system all patients
are required to have a referral from their PCP to utilize hospital
However, for an emergency department (ED) visit in
the Netherlands, a referral is not strictly needed. Many pa-
tients skip the PCP and attend the ED without referral.
Maastricht (the Netherlands), over 50% of all ED visitors were
self-referred. Increasing numbers of self-referrals and the lack
of inpatient beds can cause overcrowding at EDs.
Many patients present with non-urgent or minor primary
care problems at the ED.
Initiatives to deal with this problem
were employing PCPs in EDs, establishing a separate stream
for minor injuries, or directing patients with non-acute condi-
tions to next-day care.
Such initiatives did not focus
exclusively on out-of-hours care.
Primary care physicians in the Netherlands have a 24-
hour care responsibility to their patients. To deliver out-of-
hours care, Dutch PCPs organized themselves in locum
groups, establishing an out-of-hours coverage system.
cently, out-of-hours care in the Netherlands was reorganized
into larger PCP cooperatives, similar to the British and Danish
An important motive for this change was the
PCP’s dissatisfaction with the high and increasing workload
(out-of-hours care combined with regular work), and poor
separation between work and private life.
Usually 40 to 120 full-time PCPs participate in these
cooperatives, providing care for 80,000 to 300,000 patients.
Currently, there are over 120 PCP cooperatives in the Nether-
lands providing out-of-hours primary care for approximately
90% of the Dutch population. By and large, the cooperatives
are either situated at a central and easily accessible place at
some distance from a hospital, or are located within or adja-
cent to a hospital.
In Maastricht, the PCP cooperative aims to decrease the
number of self-referrals to the ED and to reduce the PCP’s
dissatisfaction with the former out-of-hours care system. To
that end, the Maastricht PCP cooperative was set up within the
ED of the University Hospital Maastricht. Most other out-of-
hours services—in the UK, Denmark, and in the Netherlands—
work independently of the local hospital and do not provide an
explicit gatekeeper function to specialist care. The current
organization of out-of-hours care in Maastricht forces patients
attending the ED without referral to be seen first by a PCP.
When necessary, the PCP refers the patient to the ED. Because
of this emphasis on the PCP’s gatekeeper function, we expect-
ed a shift from ED services to primary care services for minor
or non-urgent problems.
We assessed the effect of out-of-hours care in the city of
Maastricht before and after the reorganization of the PCP’s
Maastricht is a city in the south of the Netherlands with a
population of approximately 120,000 inhabitants. Out-of-hours
Accepted for publication December 15, 2004
None of the authors has any conflict of interest relevant to this
manuscript or the data.
Address correspondence and reprint requests to Dr. van Uden:
Department of Integrated Care (Bze7), University Hospital Maastricht,
P. Debyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands