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Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary... Abstract Background Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service. Objective The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service. Methods We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient’s own GP, using a questionnaire. Results Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients’ own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain. Conclusion Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain. Access to care, emergency medicine, family health, primary care, quality of care, urgent care Introduction In The Netherlands, emergency medical care is delivered by GPs or GP cooperatives (GPCs), ambulance services and accident and emergency (A&E) departments of hospitals (1). Patients with highly urgent help requests in out-of-hours have the possibility to call the ambulance service or the GPC for an immediate home visit. GPCs are responsible for urgent primary care during out-of-hours (2–4). Depending on the urgency class, patients have to be visited immediate or may be visited later. Both the GPC and the ambulance service have an own call centre with a separate emergency number. The call centre of the GPC, manned with triage nurses and a supervising GP, handles all the primary care requests for help (with different urgencies, see further) in out-of-hours and sends a GP with a medically trained driver to critically ill patients who stay at home. The frequency of life-threatening contacts in Dutch GPCs was 2.3% in 2015 (5). At the GPC, for the patients calling with acute life-threatening complaints or symptoms that probably need immediate stabilization on the spot, the ambulance service is deployed directly instead of a GP. This concerns, for instance, patients with typical complaints of a myocardial infarction or a cerebrovascular accident (CVA). On the other hand, there are diseases with the highest level of urgency that can be handled by a GP, like severe hypoglycaemia. In The Netherlands, the ambulance is staffed with a specialized emergency nurse and a medically trained driver. The ambulance service is available 24/7 for emergencies and for transport (high or low urgency) for patients at home or in public space. Ambulance care in The Netherlands is much more expensive (~€670 per response) than a visit by a GP from the GPC (~€100). On the other hand, the ambulance service is more prepared to stabilize patients with life-threatening conditions and to transport patients to the A&E department. Patients are not always able to judge which care is needed and might choose a medically unnecessarily highcare level. This can lead to inappropriate use of expensive ambulance care. Inappropriate use of ambulance services in several countries varies from 11% to 44% (6–10). When patients with serious illness have to be transported to the hospital, ambulance care is indicated. GPC care has to be delivered to patients who initially are expected to be treated and stay at home (11). The objective of our study was to determine whether highly urgent visits after a call to the GPC were delivered by the most appropriate health care provider: GPC or ambulance service. Methods Design and population We carried out a cross-sectional observational study using a retrospective medical record analysis. This includes all incoming calls to the GPC from patients resulting in a highly urgent GPC home visit or ambulance response between December 2012 and October 2014 from a large GPC in The Hague (The Netherlands) and surroundings. The GPC serves mainly urban areas with about 700000 inhabitants We used electronic medical records from the GPC to retrieve data of the visits. From the community health service of the overlapping region, we also received data of the total number of ambulance rides performed during the study period. Appropriateness of the delivered care (ambulance service or GPC) was determined by the patient’s own GP in retrospect. Procedures and variables The triage nurses of the call centre of the GPC performed the triage and divided patients in the urgency categories U0–U5, according to The Netherlands Triage Standard (12; Table 1). Table 1. Urgencies according to The Netherlands Triage Standard (13) Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day View Large Table 1. Urgencies according to The Netherlands Triage Standard (13) Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day View Large We included all U1 contacts, i.e. patients with complaints concerning a high susceptibility of a life-threatening disease which require a ‘highly urgent’ visit: patients should be seen as soon as possible. Directly after triage, the decision is made to send an ambulance or a GP to these patients. The triage nurse is supervised by a GP during this process. Calls with a high susceptibility of an acute coronary syndrome, CVA or other diseases where every minute of doctor’s delay counts and with high probability for transport to the hospital (for example, unconsciousness or severe bleeding) were, after consultation of the supervising triage GP, immediately forwarded to the ambulance service call centre with U1 indication with the request to send an ambulance to the patient. This kind of protocol-established policy is implemented in more GPCs in The Netherlands. U1 was the only criterion for inclusion; every age and International Classification of Primary Care (ICPC) code was included. Patient and care characteristics such as gender, age, day and time of call, type of care (ambulance service, GPC or both) and diagnosis were extracted from the electronic medical records according to the ICPC code. The ICPC code was documented by the triage nurse from the GPC and confirmed or corrected by a supervising GP before further assessment. Duplicates (identical contacts extracted from both the ambulance service and the GPC files) and contacts with missing data were excluded. Follow-up A questionnaire was sent to the patient’s own GP in which we asked them to determine the most appropriate type of care and urgency in retrospect. Additional information was also obtained concerning hospital attendance and care, and the GPs were asked whether the initial ICPC code from the GPC had been changed afterwards. Ethical considerations The Ethical Research Committee of the Radboud University Medical Center, Nijmegen was consulted and concluded that this study does not fall within the remit of the Dutch Medical Research Involving Human Subjects Act [Wet Mensgebonden Onderzoek] (file number 2014-299). Analysis Descriptive statistics were used to describe the population variables. Differences between groups were tested with chi-square tests. Data were analysed using the Statistical Package of the Social Sciences (SPSS22). Results were considered significant at P < 0.05. Results Population Out of the 1960 U1 visits, 709 were duplicates and 170 had missing data. After exclusion of these records, 1081 U1 visits remained. From the 1081 questionnaires send to the own GPs of the patients, 598 were eligible for analysis (response rate 55.3%; Figure 1). During the study period, there were 4776 U1 ambulance responses in out-of-hours in the same catchment area. Figure 1. View largeDownload slide Flow-chart of the number of contacts used for the analyses. Asterisk indicates missing data, relevant missing elements in electronic files of either GP cooperative (GPC) or ambulance service. Figure 1. View largeDownload slide Flow-chart of the number of contacts used for the analyses. Asterisk indicates missing data, relevant missing elements in electronic files of either GP cooperative (GPC) or ambulance service. Patient and care characteristics Table 2 shows patient and care characteristics of all included U1 visits (n = 1081). In 401 cases a GP from the GPC performed a home visit immediately, in 570 cases the call was forwarded to the ambulance service resulting in ambulance response and in 110 cases both the GP and an ambulance were deployed immediately. This means that, in out-of-hours, 14.2% (680/4776) of the U1 ambulance responses had been forwarded from the GPC. Table 2. Patient and care characteristics Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P < 0.05 (GPC as reference group). View Large Table 2. Patient and care characteristics Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P < 0.05 (GPC as reference group). View Large In all groups, the majority of the patients were women. In the youngest (0–24 years) and the oldest (>85 years) age groups, patients were more likely to receive GPC care. During the night time, ambulance deployment was relatively more frequent than GPC care (GPC 26.7%, ambulance 39.6%, ambulance and GPC 28.2%). We found diagnosis concerning the respiratory tract to be most common in the GPC group (28.4%), as well as in the ‘ambulance and GPC’ group (26.4%). Chest pain was the main reason for ambulance deployment (60.7%). Follow-up As judged by the patient’s own GP in the follow-up questionnaire, many visits carried out with an urgency U1 should have been carried out with a lower urgency in retrospect (GPC 49.0%, ambulance 41.0%, ambulance and GPC 27.6%; Table 3). According to the responding GPs, 60% in the GPC group received the preferred type of care, compared with 51% in the ambulance group and 25% in the ‘ambulance and GPC’ group. After judgement of the own GP, 35.9% of the documented ICPC codes changed in the GPC group and 61.3% in the ambulance group (P < 0.05). Table 3. Results of questionnaires from follow-up own GP GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC, GP cooperative; ICPC, International Classification of Primary Care. aP-values not shown. *P < 0.05 (GPC as reference group). View Large Table 3. Results of questionnaires from follow-up own GP GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC, GP cooperative; ICPC, International Classification of Primary Care. aP-values not shown. *P < 0.05 (GPC as reference group). View Large From the obtained questionnaires, we further analysed differences between characteristics of the patients who were not referred, referred to the A&E department (but not admitted to the hospital), and patients who were admitted to the hospital (Table 4). Patients for whom only an ambulance was deployed were more likely to be referred to the A&E department (83.1% versus 47.9% in the GPC group), but also more likely to be discharged home after A&E assessment (24.4% versus 12.1% in the GPC group). Of the patients with chest pain, 125 of 221 (56.6%) were admitted to the hospital, compared with 21 of 24 (87.5%) of the patients with suspected CVA. Table 4. Differences between patients who were not referred, referred to the A&E department and admitted to the hospital Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* A&E, accident and emergency; CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P ≤ 0.05 (not referred to A&E as reference group). View Large Table 4. Differences between patients who were not referred, referred to the A&E department and admitted to the hospital Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* A&E, accident and emergency; CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P ≤ 0.05 (not referred to A&E as reference group). View Large Discussion Principal findings and interpretation More than half of the highly urgent (U1) visits indeed concern high urgent care, as judged by the patient’s own GP in retrospect. The remaining part should be qualified with a lower urgency (overtriage). About 40% of the U1 visits from the GPC and the ambulance service probably should have been carried out by a different healthcare provider, according to the patient’s own GP. In 10% of the cases, both the ambulance service and the GPC responded immediately, which resulted in hospital admission in >80% of these cases. In hindsight, in this group U1 was most frequently confirmed as appropriate. To deliver care as efficient as possible, ambulance response is appropriate in case of subsequent hospital admission and GPC care in case the patient can be treated at home. Reasons to deploy both ambulance and GPC could be either to provide care as soon as possible or to have more expertise and means available at the scene to provide care as needed. We expected suspicion of an acute coronary syndrome or CVA to be common diagnosis in the ambulance group, as triage protocols of GPCs advise immediate ambulance deployment in these cases. The rationale is that the limitation of time to revascularization is crucial for preservation of vital organs. The reduction of this delay was one of the key elements in the decrease of mortality from cardiovascular diseases in the last decades (14). However, our study showed a great contrast between the group of patients in which a CVA was suspected and patients with chest pain. The group of suspected CVAs was relatively small (4%) and 84% of these patients were subsequently admitted to the hospital. Chest pain occurred more frequently (40%), and only 57% of these patients were admitted. Other research shows that few patients (6%) who present to the ambulance service by telephone with chest pain eventually turn out to have an acute coronary syndrome (15) and 22% of the patients presenting to an A&E department for chest pain are subsequently diagnosed with an acute coronary syndrome (16). For many patients who were diagnosed with a non-urgent cause (e.g. anxiety or musculoskeletal chest pain), in retrospect an emergency ambulance was the preferred deployment in our study. A more limited ambulance deployment in case of chest pain might save substantial healthcare costs, but this could also lead to a failure to supply the optimal care for patients with a true myocardial infarction. A study by Hettinger et al. shows that several dispatch factors (like ‘fainting’ or ‘sexual assault’) are known with a high predictive value of discharge from the emergency department. Note that these cases often validly are presented to the A&E department (17). On the other hand, some factors predict non-transport of emergency home visits (18). Strengths and limitations To our knowledge, this is the first study in which patient and care characteristics are explored of home visits to patients with life-threatening conditions conducted by a GPC or ambulance (with or without transport). We used a large sample of contacts (n = 1081) for analysis. We used a combination of routine data on patient and care characteristics and a follow-up judgment by the patients’ own GP. To our opinion, the patient’s own GP can most accurately determine the most appropriate type and urgency of care in hindsight. Furthermore, the questionnaire send to the own GPs provided additional follow-up data to our study. However, this method also introduced several limitations. First, it poses a risk of selection bias as only 55% of the questionnaires were returned. As the rate of return of the questionnaires was similar for the GPC and ambulance group, we do not expect a major influence on the results. Secondly, the judgment of the patients’ own GP about the appropriate urgency and deployment is subjective. Determining the need for ambulance deployment using the final diagnosis or the need for life- or organ-saving treatment in the first hour would be more objective. This approach would result in a far greater rate of overtreatment, but at the time the decision for immediate ambulance deployment has to be made, outcome cannot be predicted. Another limitation is the collection of data in one urban area of The Netherlands, so the results might not be representative for other rural or urban areas in our country. Finally, other factors than the medical condition of the patient may have played a role in decision making, like the availability of the GP and ambulance at the time of the call. Comparison with existing literature A Dutch study evaluating the ambulance service showed that 42% of the emergency call-outs might be replaced by a GP visit (19). In other countries, the inappropriate use of the ambulances varied from 11% to 44% (6–10). Our data appear to be in line with these results. Former studies concerning comparison of patient and care characteristics of life-threatening complaints between GPC versus ambulance service were not found. Only some studies about triage nurses at GPCs are conducted. It appears that they perform well for low urgent complaints, but that there could be made some improvement in case of highly urgent contacts (20,21). In Norway, several studies were performed in the pre-hospital setting, investigating highly urgent contacts and contacts due to chest pain (22–25). Caution must be taken to compare studies performed in The Netherlands and Norway due to big differences in population density and travel distances. A higher response rate from both ambulance service and GP in Norway can be explained by logistic problems to arrive in time at the scene for ambulances in remote areas. However, similar results as in our study were found regarding the high proportion of chest pain in highly urgent contacts, and the relatively low rate of subsequent hospital admission in these patients (25). Implications for research and/or practice The high frequencies of inappropriate care in our study suggest a possibility for improvement in this population. One could think of efforts to introduce more (conclusive) predictive factors in the triage process. However, some degree of overtriage is acceptable to prevent undertriage. The increase of undertriage should be monitored after introduction of an intervention aiming to limit overtriage. It is important to notice that a high percentage of U1 calls concern chest pain. These cases are often interpreted as a possible myocardial infarction for which ambulance response is appropriate. Although more than half of these patients were admitted to the hospital, only a small fraction (which was not measured in our study) received an acute intervention. Efforts should focus on strategies limiting unnecessary ambulance deployment in patients with chest pain. Unfortunately, we could not identify low-risk groups, and a more stringent policy for ambulance response will probably result in missed myocardial infractions. We recommend training of triage nurses and GPs in recognizing acute coronary syndrome by the use of (modified) decision rules like the Marburg Heart Score (26). A relatively large proportion of overtriage will still remain in patients with chest pain after triage. Reduction of unnecessary ambulance responses without compromise of patient safety might only be feasible, if GPs are equipped to quickly obtain an ECG and possibly cardiac markers using point-of-care testing. Not only diagnostic accuracy, but also effects on time to hospital arrival should be investigated thoroughly before such an approach is implemented in daily practice. In general, it would be favourable to enlarge the amount of available data of patients to triage nurses, like the medical history, use of medication or previous hospitalizations to enable them to assign the most appropriate type of care. Moreover, it might be useful to merge call centres of GPC and ambulance service to converge the available competence. Conclusion Our results show that the quality of out-of-hours primary care for patients with life-threatening conditions can be improved for GPCs as well as the ambulance service: there is a relatively large amount of overtriage and a suboptimal distribution of care in patients with highly urgent complaints. Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate health care provider, especially for patients with chest pain. Acknowledgements We thank Ms. M. Smits (PhD) from IQ healthcare for useful comments on the manuscript. Declaration Funding: This study was financially supported by the Mobile Doctors Service Foundation Haaglanden (Stichting Mobiele Artsen Service Haaglanden) and by the Municipal Health Service Haaglanden (Gemeentelijke Gezondheidsdienst Haaglanden). Ethical approval: The Ethical Research Committee of the Radboud university medical center Nijmegen was consulted and concluded that this study does not fall within the remit of the Dutch Medical Research Involving Human Subjects Act [Wet Mensgebonden Onderzoek] (file number 2014-299). Conflict of interest: The authors declare that they have no competing interests. References 1. Grol R , Giesen P , van Uden C . After-hours care in the United Kingdom, Denmark, and the Netherlands: new models . Health Aff (Millwood) 2006 ; 25 : 1733 – 7 . Google Scholar CrossRef Search ADS PubMed 2. Smits M , Rutten M , Keizer E , et al. The development and performance of after-hours primary care in the Netherlands: a narrative review . Ann Intern Med 2017 ; 166 : 737 – 42 . Google Scholar CrossRef Search ADS PubMed 3. van Uden CJ , Giesen PH , Metsemakers JF , et al. Development of out-of-hours primary care by general practitioners (GPs) in The Netherlands: from small-call rotations to large-scale GP cooperatives . Fam Med 2006 ; 38 : 565 – 9 . Google Scholar PubMed 4. Huibers L , Giesen P , Wensing M , et al. Out-of-hours care in western countries: assessment of different organizational models . BMC Health Serv Res 2009 ; 9 : 105 . Google Scholar CrossRef Search ADS PubMed 5. InEen . [Benchmarkbulletin GPCs] . http://ineen.nl/wp-content/uploads/ 2016/08/160818-Benchmarkbulletin-2015-Huisartsenposten-def.pdf (accessed on 14 July 2017) . 6. Billittier AJ , Moscati R , Janicke D , et al. A multisite survey of factors contributing to medically unnecessary ambulance transports . Acad Emerg Med 1996 ; 3 : 1046 – 52 . Google Scholar CrossRef Search ADS PubMed 7. Richards JR , Ferrall SJ . Inappropriate use of emergency medical services transport: comparison of provider and patient perspectives . Acad Emerg Med 1999 ; 6 : 14 – 20 . Google Scholar CrossRef Search ADS PubMed 8. Patterson PD , Baxley EG , Probst JC , et al. Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years . Matern Child Health J 2006 ; 10 : 527 – 36 . Google Scholar CrossRef Search ADS PubMed 9. Horibata K , Takemura Y . Inappropriate use of ambulance services by elderly patients with less urgent medical needs . Tohoku J Exp Med 2015 ; 235 : 89 – 95 . Google Scholar CrossRef Search ADS PubMed 10. Patton GG , Thakore S . Reducing inappropriate emergency department attendances–a review of ambulance service attendances at a regional teaching hospital in Scotland . Emerg Med J 2013 ; 30 : 459 – 61 . Google Scholar CrossRef Search ADS PubMed 11. Willekens M , Giesen P , Plat E , et al. Quality of after-hours primary care in The Netherlands: adherence to national guidelines . BMJ Qual Saf 2011 ; 20 : 223 – 7 . Google Scholar CrossRef Search ADS PubMed 12. van Ierland Y , van Veen M , Huibers L , et al. Validity of telephone and physical triage in emergency care: the Netherlands triage system . Fam Pract 2011 ; 28 : 334 – 41 . Google Scholar CrossRef Search ADS PubMed 13. Nederlands Triage Systeem [Dutch Triage System]www.de-nts.nl (accessed on 14 July 2017) . 14. Laribi S , Aouba A , Resche-Rigon M , et al. Trends in death attributed to myocardial infarction, heart failure and pulmonary embolism in Europe and Canada over the last decade . QJM 2014 ; 107 : 813 – 20 . Google Scholar CrossRef Search ADS PubMed 15. Deakin CD , Sherwood DM , Smith A , et al. Does telephone triage of emergency (999) calls using Advanced Medical Priority Dispatch (AMPDS) with Department of Health (DH) call prioritisation effectively identify patients with an acute coronary syndrome? An audit of 42,657 emergency calls to Hampshire ambulance service NHS trust . Emerg Med J 2006 ; 23 : 232 – 5 . Google Scholar CrossRef Search ADS PubMed 16. Baccouche H , Belguith AS , Boubaker H , et al. Acute coronary syndrome among patients with chest pain: prevalence, incidence and risk factors . Int J Cardiol 2016 ; 214 : 531 – 5 . Google Scholar CrossRef Search ADS PubMed 17. Hettinger AZ , Cushman JT , Shah MN , et al. Emergency medical dispatch codes association with emergency department outcomes . Prehosp Emerg Care 2013 ; 17 : 29 – 37 . Google Scholar CrossRef Search ADS PubMed 18. Hodell EM , Sporer KA , Brown JF . Which emergency medical dispatch codes predict high prehospital nontransport rates in an urban community ? Prehosp Emerg Care 2014 ; 18 : 28 – 34 . Google Scholar CrossRef Search ADS PubMed 19. Smits M , Francissen O , Weerts M , et al. [Emergency ambulance call-outs often provide primary care] . Ned Tijdschr Geneeskd 2014 ; 158 : A7863 . Google Scholar PubMed 20. Huibers L , Keizer E , Giesen P , et al. Nurse telephone triage: good quality associated with appropriate decisions . Fam Pract 2012 ; 29 : 547 – 52 . Google Scholar CrossRef Search ADS PubMed 21. Huibers L , Smits M , Renaud V , et al. Safety of telephone triage in out-of-hours care: a systematic review . Scand J Prim Health Care 2011 ; 29 : 198 – 209 . Google Scholar CrossRef Search ADS PubMed 22. Burman RA , Zakariassen E , Hunskaar S . Management of chest pain: a prospective study from Norwegian out-of-hours primary care . BMC Fam Pract 2014 ; 15 : 51 . Google Scholar CrossRef Search ADS PubMed 23. Rørtveit S , Meland E , Hunskaar S . Changes of triage by GPs during the course of prehospital emergency situations in a Norwegian rural community . Scand J Trauma Resusc Emerg Med 2013 ; 21 : 89 . Google Scholar CrossRef Search ADS PubMed 24. Zakariassen E , Hunskaar S . Involvement in emergency situations by primary care doctors on-call in Norway–a prospective population-based observational study . BMC Emerg Med 2010 ; 10 : 5 . Google Scholar CrossRef Search ADS PubMed 25. Burman RA , Zakariassen E , Hunskaar S . Acute chest pain—a prospective population based study of contacts to Norwegian emergency medical communication centres . BMC Emerg Med 2011 ; 11 : 9 . Google Scholar CrossRef Search ADS PubMed 26. Haasenritter J , Bösner S , Vaucher P , et al. Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule . Br J Gen Pract 2012 ; 62 : e415 – 21 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care

Family Practice , Volume Advance Article (4) – Dec 20, 2017
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10.1093/fampra/cmx121
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Abstract

Abstract Background Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service. Objective The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service. Methods We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient’s own GP, using a questionnaire. Results Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients’ own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain. Conclusion Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain. Access to care, emergency medicine, family health, primary care, quality of care, urgent care Introduction In The Netherlands, emergency medical care is delivered by GPs or GP cooperatives (GPCs), ambulance services and accident and emergency (A&E) departments of hospitals (1). Patients with highly urgent help requests in out-of-hours have the possibility to call the ambulance service or the GPC for an immediate home visit. GPCs are responsible for urgent primary care during out-of-hours (2–4). Depending on the urgency class, patients have to be visited immediate or may be visited later. Both the GPC and the ambulance service have an own call centre with a separate emergency number. The call centre of the GPC, manned with triage nurses and a supervising GP, handles all the primary care requests for help (with different urgencies, see further) in out-of-hours and sends a GP with a medically trained driver to critically ill patients who stay at home. The frequency of life-threatening contacts in Dutch GPCs was 2.3% in 2015 (5). At the GPC, for the patients calling with acute life-threatening complaints or symptoms that probably need immediate stabilization on the spot, the ambulance service is deployed directly instead of a GP. This concerns, for instance, patients with typical complaints of a myocardial infarction or a cerebrovascular accident (CVA). On the other hand, there are diseases with the highest level of urgency that can be handled by a GP, like severe hypoglycaemia. In The Netherlands, the ambulance is staffed with a specialized emergency nurse and a medically trained driver. The ambulance service is available 24/7 for emergencies and for transport (high or low urgency) for patients at home or in public space. Ambulance care in The Netherlands is much more expensive (~€670 per response) than a visit by a GP from the GPC (~€100). On the other hand, the ambulance service is more prepared to stabilize patients with life-threatening conditions and to transport patients to the A&E department. Patients are not always able to judge which care is needed and might choose a medically unnecessarily highcare level. This can lead to inappropriate use of expensive ambulance care. Inappropriate use of ambulance services in several countries varies from 11% to 44% (6–10). When patients with serious illness have to be transported to the hospital, ambulance care is indicated. GPC care has to be delivered to patients who initially are expected to be treated and stay at home (11). The objective of our study was to determine whether highly urgent visits after a call to the GPC were delivered by the most appropriate health care provider: GPC or ambulance service. Methods Design and population We carried out a cross-sectional observational study using a retrospective medical record analysis. This includes all incoming calls to the GPC from patients resulting in a highly urgent GPC home visit or ambulance response between December 2012 and October 2014 from a large GPC in The Hague (The Netherlands) and surroundings. The GPC serves mainly urban areas with about 700000 inhabitants We used electronic medical records from the GPC to retrieve data of the visits. From the community health service of the overlapping region, we also received data of the total number of ambulance rides performed during the study period. Appropriateness of the delivered care (ambulance service or GPC) was determined by the patient’s own GP in retrospect. Procedures and variables The triage nurses of the call centre of the GPC performed the triage and divided patients in the urgency categories U0–U5, according to The Netherlands Triage Standard (12; Table 1). Table 1. Urgencies according to The Netherlands Triage Standard (13) Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day View Large Table 1. Urgencies according to The Netherlands Triage Standard (13) Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day Urgency code Description Response time U0 Resuscitation Immediate U1 Life-threatening As soon as possible U2 Emergent Within 1 hour U3 Urgent Within a few hours U4 Non-urgent Within 24 hours U5 Advice Next working day View Large We included all U1 contacts, i.e. patients with complaints concerning a high susceptibility of a life-threatening disease which require a ‘highly urgent’ visit: patients should be seen as soon as possible. Directly after triage, the decision is made to send an ambulance or a GP to these patients. The triage nurse is supervised by a GP during this process. Calls with a high susceptibility of an acute coronary syndrome, CVA or other diseases where every minute of doctor’s delay counts and with high probability for transport to the hospital (for example, unconsciousness or severe bleeding) were, after consultation of the supervising triage GP, immediately forwarded to the ambulance service call centre with U1 indication with the request to send an ambulance to the patient. This kind of protocol-established policy is implemented in more GPCs in The Netherlands. U1 was the only criterion for inclusion; every age and International Classification of Primary Care (ICPC) code was included. Patient and care characteristics such as gender, age, day and time of call, type of care (ambulance service, GPC or both) and diagnosis were extracted from the electronic medical records according to the ICPC code. The ICPC code was documented by the triage nurse from the GPC and confirmed or corrected by a supervising GP before further assessment. Duplicates (identical contacts extracted from both the ambulance service and the GPC files) and contacts with missing data were excluded. Follow-up A questionnaire was sent to the patient’s own GP in which we asked them to determine the most appropriate type of care and urgency in retrospect. Additional information was also obtained concerning hospital attendance and care, and the GPs were asked whether the initial ICPC code from the GPC had been changed afterwards. Ethical considerations The Ethical Research Committee of the Radboud University Medical Center, Nijmegen was consulted and concluded that this study does not fall within the remit of the Dutch Medical Research Involving Human Subjects Act [Wet Mensgebonden Onderzoek] (file number 2014-299). Analysis Descriptive statistics were used to describe the population variables. Differences between groups were tested with chi-square tests. Data were analysed using the Statistical Package of the Social Sciences (SPSS22). Results were considered significant at P < 0.05. Results Population Out of the 1960 U1 visits, 709 were duplicates and 170 had missing data. After exclusion of these records, 1081 U1 visits remained. From the 1081 questionnaires send to the own GPs of the patients, 598 were eligible for analysis (response rate 55.3%; Figure 1). During the study period, there were 4776 U1 ambulance responses in out-of-hours in the same catchment area. Figure 1. View largeDownload slide Flow-chart of the number of contacts used for the analyses. Asterisk indicates missing data, relevant missing elements in electronic files of either GP cooperative (GPC) or ambulance service. Figure 1. View largeDownload slide Flow-chart of the number of contacts used for the analyses. Asterisk indicates missing data, relevant missing elements in electronic files of either GP cooperative (GPC) or ambulance service. Patient and care characteristics Table 2 shows patient and care characteristics of all included U1 visits (n = 1081). In 401 cases a GP from the GPC performed a home visit immediately, in 570 cases the call was forwarded to the ambulance service resulting in ambulance response and in 110 cases both the GP and an ambulance were deployed immediately. This means that, in out-of-hours, 14.2% (680/4776) of the U1 ambulance responses had been forwarded from the GPC. Table 2. Patient and care characteristics Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P < 0.05 (GPC as reference group). View Large Table 2. Patient and care characteristics Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) Results of U1 visits GPC n = 401 n (%) Ambulance service n = 570 n (%) Ambulance and GPC n = 110 n (%) Female 241 (60.1) 324 (56.8) 66 (60.0) Age category  0–24 years 40 (10.0) 32 (5.6)* 4 (3.6)*  25–64 years 107 (26.7) 237 (41.6)* 39 (35.5)  65–84 years 148 (36.9) 201 (35.3) 39 (35.5)  85+ years 106 (26.4) 100 (17.5)* 28 (25.5) Moment of visit  Evening, 17–24 h 194 (48.4) 245 (43.0) 61 (55.5)  Weekend, 8–17 h 100 (24.9) 99 (17.4)* 18 (16.4)  Night, 0–8 h 107 (26.7) 226 (39.6)* 31 (28.2) ICPC category  Respiratory tract 114 (28.4) 46 (8.1)* 29 (26.4)  Chest paina 33 (8.2) 346 (60.7)* 10 (9.1)  CVAb 8 (2.0) 34 (6.0)* 3 (2.7) CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P < 0.05 (GPC as reference group). View Large In all groups, the majority of the patients were women. In the youngest (0–24 years) and the oldest (>85 years) age groups, patients were more likely to receive GPC care. During the night time, ambulance deployment was relatively more frequent than GPC care (GPC 26.7%, ambulance 39.6%, ambulance and GPC 28.2%). We found diagnosis concerning the respiratory tract to be most common in the GPC group (28.4%), as well as in the ‘ambulance and GPC’ group (26.4%). Chest pain was the main reason for ambulance deployment (60.7%). Follow-up As judged by the patient’s own GP in the follow-up questionnaire, many visits carried out with an urgency U1 should have been carried out with a lower urgency in retrospect (GPC 49.0%, ambulance 41.0%, ambulance and GPC 27.6%; Table 3). According to the responding GPs, 60% in the GPC group received the preferred type of care, compared with 51% in the ambulance group and 25% in the ‘ambulance and GPC’ group. After judgement of the own GP, 35.9% of the documented ICPC codes changed in the GPC group and 61.3% in the ambulance group (P < 0.05). Table 3. Results of questionnaires from follow-up own GP GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC, GP cooperative; ICPC, International Classification of Primary Care. aP-values not shown. *P < 0.05 (GPC as reference group). View Large Table 3. Results of questionnaires from follow-up own GP GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC n (%) Ambulance service n (%) Ambulance and GPC n (%) Urgency (in retrospect) n = 200 n = 293 n = 58  U1 102 (51.0) 173 (59.0) 42 (72.4)*  U2 69 (34.5) 77 (26.3)* 13 (22.4)  U3 24 (12.0) 36 (12.3) 3 (5.2)  U4 2 (1.0) 4 (1.4) 0 (0)  U5 3 (1.5) 3 (1.0) 0 (0) Preferred type of care (in retrospect)a n = 196 n = 301 n = 56  GPC visit 119 (60.7) 93 (30.9) 21 (37.5)  Ambulance service 38 (19.4) 153 (50.8) 21 (37.5)  Ambulance and GPC 22 (11.2) 23 (7.6) 14 (25.0)  Consultation at GPC 14 (7.1) 23 (7.6) 0 (0)  Telephone consultation 1 (0.5) 2 (0.7) 0 (0)  Own GP the next day 2 (1.0) 6 (2.0) 0 (0)  Self-care advice 0 (0.0) 1 (0.3) 0 (0) Altered ICPC-code (%) 35.9 63.8* 47.6 GPC, GP cooperative; ICPC, International Classification of Primary Care. aP-values not shown. *P < 0.05 (GPC as reference group). View Large From the obtained questionnaires, we further analysed differences between characteristics of the patients who were not referred, referred to the A&E department (but not admitted to the hospital), and patients who were admitted to the hospital (Table 4). Patients for whom only an ambulance was deployed were more likely to be referred to the A&E department (83.1% versus 47.9% in the GPC group), but also more likely to be discharged home after A&E assessment (24.4% versus 12.1% in the GPC group). Of the patients with chest pain, 125 of 221 (56.6%) were admitted to the hospital, compared with 21 of 24 (87.5%) of the patients with suspected CVA. Table 4. Differences between patients who were not referred, referred to the A&E department and admitted to the hospital Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* A&E, accident and emergency; CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P ≤ 0.05 (not referred to A&E as reference group). View Large Table 4. Differences between patients who were not referred, referred to the A&E department and admitted to the hospital Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* Not referred to A&E department n = 166 n (%) Referred to A&E, not admitted to hospital n = 108 n (%) Admitted to hospital n = 303 n (%) Female 106 (63.9) 63 (58.3) 172 (56.8) Age category  0–24 years 20 (12.0) 15 (13.9) 5 (1.7)*  25–64 years 63 (38.0) 58 (53.7)* 86 (28.4)*  65–84 years 50 (30.1) 24 (22.2) 138 (45.5)*  85+ years 33 (19.9) 11 (10.2)* 74 (24.4) Deployment  GPC 110 (66.3) 25 (23.1)* 72 (23.8)*  Ambulance service 52 (31.3) 75 (69.4)* 180 (59.4)*  Ambulance and GPC 4 (2.4) 8 (7.4)* 51 (16.8)* ICPC-code category  Respiratory tract 40 (24.1) 11 (10.2)* 44 (14.5)*  Chest paina 36 (21.7) 60 (55.6)* 125 (41.3)*  CVAb 1 (0.6) 3 (2.8) 21 (6.9)*  Other 89 (53.6) 34 (31.5)* 113 (37.3)* A&E, accident and emergency; CVA, cerebrovascular accident; GPC, GP cooperative; ICPC, International Classification of Primary Care. aCombination of ICPC-codes: K01.00, K02.00, K24.00, K74.00, K74.01, K75.00, L04.00. bICPC-code K90.00. *P ≤ 0.05 (not referred to A&E as reference group). View Large Discussion Principal findings and interpretation More than half of the highly urgent (U1) visits indeed concern high urgent care, as judged by the patient’s own GP in retrospect. The remaining part should be qualified with a lower urgency (overtriage). About 40% of the U1 visits from the GPC and the ambulance service probably should have been carried out by a different healthcare provider, according to the patient’s own GP. In 10% of the cases, both the ambulance service and the GPC responded immediately, which resulted in hospital admission in >80% of these cases. In hindsight, in this group U1 was most frequently confirmed as appropriate. To deliver care as efficient as possible, ambulance response is appropriate in case of subsequent hospital admission and GPC care in case the patient can be treated at home. Reasons to deploy both ambulance and GPC could be either to provide care as soon as possible or to have more expertise and means available at the scene to provide care as needed. We expected suspicion of an acute coronary syndrome or CVA to be common diagnosis in the ambulance group, as triage protocols of GPCs advise immediate ambulance deployment in these cases. The rationale is that the limitation of time to revascularization is crucial for preservation of vital organs. The reduction of this delay was one of the key elements in the decrease of mortality from cardiovascular diseases in the last decades (14). However, our study showed a great contrast between the group of patients in which a CVA was suspected and patients with chest pain. The group of suspected CVAs was relatively small (4%) and 84% of these patients were subsequently admitted to the hospital. Chest pain occurred more frequently (40%), and only 57% of these patients were admitted. Other research shows that few patients (6%) who present to the ambulance service by telephone with chest pain eventually turn out to have an acute coronary syndrome (15) and 22% of the patients presenting to an A&E department for chest pain are subsequently diagnosed with an acute coronary syndrome (16). For many patients who were diagnosed with a non-urgent cause (e.g. anxiety or musculoskeletal chest pain), in retrospect an emergency ambulance was the preferred deployment in our study. A more limited ambulance deployment in case of chest pain might save substantial healthcare costs, but this could also lead to a failure to supply the optimal care for patients with a true myocardial infarction. A study by Hettinger et al. shows that several dispatch factors (like ‘fainting’ or ‘sexual assault’) are known with a high predictive value of discharge from the emergency department. Note that these cases often validly are presented to the A&E department (17). On the other hand, some factors predict non-transport of emergency home visits (18). Strengths and limitations To our knowledge, this is the first study in which patient and care characteristics are explored of home visits to patients with life-threatening conditions conducted by a GPC or ambulance (with or without transport). We used a large sample of contacts (n = 1081) for analysis. We used a combination of routine data on patient and care characteristics and a follow-up judgment by the patients’ own GP. To our opinion, the patient’s own GP can most accurately determine the most appropriate type and urgency of care in hindsight. Furthermore, the questionnaire send to the own GPs provided additional follow-up data to our study. However, this method also introduced several limitations. First, it poses a risk of selection bias as only 55% of the questionnaires were returned. As the rate of return of the questionnaires was similar for the GPC and ambulance group, we do not expect a major influence on the results. Secondly, the judgment of the patients’ own GP about the appropriate urgency and deployment is subjective. Determining the need for ambulance deployment using the final diagnosis or the need for life- or organ-saving treatment in the first hour would be more objective. This approach would result in a far greater rate of overtreatment, but at the time the decision for immediate ambulance deployment has to be made, outcome cannot be predicted. Another limitation is the collection of data in one urban area of The Netherlands, so the results might not be representative for other rural or urban areas in our country. Finally, other factors than the medical condition of the patient may have played a role in decision making, like the availability of the GP and ambulance at the time of the call. Comparison with existing literature A Dutch study evaluating the ambulance service showed that 42% of the emergency call-outs might be replaced by a GP visit (19). In other countries, the inappropriate use of the ambulances varied from 11% to 44% (6–10). Our data appear to be in line with these results. Former studies concerning comparison of patient and care characteristics of life-threatening complaints between GPC versus ambulance service were not found. Only some studies about triage nurses at GPCs are conducted. It appears that they perform well for low urgent complaints, but that there could be made some improvement in case of highly urgent contacts (20,21). In Norway, several studies were performed in the pre-hospital setting, investigating highly urgent contacts and contacts due to chest pain (22–25). Caution must be taken to compare studies performed in The Netherlands and Norway due to big differences in population density and travel distances. A higher response rate from both ambulance service and GP in Norway can be explained by logistic problems to arrive in time at the scene for ambulances in remote areas. However, similar results as in our study were found regarding the high proportion of chest pain in highly urgent contacts, and the relatively low rate of subsequent hospital admission in these patients (25). Implications for research and/or practice The high frequencies of inappropriate care in our study suggest a possibility for improvement in this population. One could think of efforts to introduce more (conclusive) predictive factors in the triage process. However, some degree of overtriage is acceptable to prevent undertriage. The increase of undertriage should be monitored after introduction of an intervention aiming to limit overtriage. It is important to notice that a high percentage of U1 calls concern chest pain. These cases are often interpreted as a possible myocardial infarction for which ambulance response is appropriate. Although more than half of these patients were admitted to the hospital, only a small fraction (which was not measured in our study) received an acute intervention. Efforts should focus on strategies limiting unnecessary ambulance deployment in patients with chest pain. Unfortunately, we could not identify low-risk groups, and a more stringent policy for ambulance response will probably result in missed myocardial infractions. We recommend training of triage nurses and GPs in recognizing acute coronary syndrome by the use of (modified) decision rules like the Marburg Heart Score (26). A relatively large proportion of overtriage will still remain in patients with chest pain after triage. Reduction of unnecessary ambulance responses without compromise of patient safety might only be feasible, if GPs are equipped to quickly obtain an ECG and possibly cardiac markers using point-of-care testing. Not only diagnostic accuracy, but also effects on time to hospital arrival should be investigated thoroughly before such an approach is implemented in daily practice. In general, it would be favourable to enlarge the amount of available data of patients to triage nurses, like the medical history, use of medication or previous hospitalizations to enable them to assign the most appropriate type of care. Moreover, it might be useful to merge call centres of GPC and ambulance service to converge the available competence. Conclusion Our results show that the quality of out-of-hours primary care for patients with life-threatening conditions can be improved for GPCs as well as the ambulance service: there is a relatively large amount of overtriage and a suboptimal distribution of care in patients with highly urgent complaints. Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate health care provider, especially for patients with chest pain. Acknowledgements We thank Ms. M. Smits (PhD) from IQ healthcare for useful comments on the manuscript. Declaration Funding: This study was financially supported by the Mobile Doctors Service Foundation Haaglanden (Stichting Mobiele Artsen Service Haaglanden) and by the Municipal Health Service Haaglanden (Gemeentelijke Gezondheidsdienst Haaglanden). Ethical approval: The Ethical Research Committee of the Radboud university medical center Nijmegen was consulted and concluded that this study does not fall within the remit of the Dutch Medical Research Involving Human Subjects Act [Wet Mensgebonden Onderzoek] (file number 2014-299). Conflict of interest: The authors declare that they have no competing interests. References 1. Grol R , Giesen P , van Uden C . After-hours care in the United Kingdom, Denmark, and the Netherlands: new models . Health Aff (Millwood) 2006 ; 25 : 1733 – 7 . Google Scholar CrossRef Search ADS PubMed 2. Smits M , Rutten M , Keizer E , et al. The development and performance of after-hours primary care in the Netherlands: a narrative review . Ann Intern Med 2017 ; 166 : 737 – 42 . Google Scholar CrossRef Search ADS PubMed 3. van Uden CJ , Giesen PH , Metsemakers JF , et al. 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Family Practice – Oxford University Press

Published: Dec 20, 2017

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