Safety, efficiency and health-related quality of telephone triage conducted by general practitioners, nurses, or physicians in out-of-hours primary care: a quasi-experimental study using the Assessment of Quality in Telephone Triage (AQTT) to assess audio-recorded telephone calls.

BACKGROUND: To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities. METHODS: Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n = 423), nurses using CDSS (n = 430), or physicians with different medical specialities (n = 441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage. RESULTS: The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2 min 57 s, SD: 105 s) than nurses (mean: 4 min 44 s, SD: 168 s). CONCLUSIONS: Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.

Quality of out-of-hours telephone triage by general practitioners and nurses: development and testing of the AQTT - an assessment tool measuring communication, patient safety and efficiency.

OBJECTIVE: To develop a valid and reliable assessment tool able to measure quality of communication, patient safety and efficiency in out-of-hours (OOH) telephone triage conducted by both general practitioners (GP) and nurses. DESIGN: The Dutch KERNset tool was translated into Danish and supplemented with items from other existing tools. Face validity, content validity and applicability in OOH telephone triage (OOH-TT) were secured through a two-round Delphi process involving relevant stakeholders. Forty-eight OOH patient contacts were assessed by 24 assessors in test-retest and inter-rater designs. SETTING: OOH-TT services in Denmark conducted by GPs, nurses or doctors with varying medical specialisation. PATIENTS: Audio-recorded OOH patient contacts. MAIN OUTCOME MEASURES: Test-retest and inter-rater reliability were analysed using ICCagreement, Fleiss' kappa and percent agreement. RESULTS: Major adaptations during the Delphi process were made. The 24-item assessment tool (Assessment of Quality in Telephone Triage - AQTT) measured communicative quality, health-related quality and four overall quality aspects. The test-retest ICCagreement reliability was good for the overall quality of communication (0.85), health-related quality (0.83), patient safety (0.81) and efficiency (0.77) and satisfactory when assessing specific aspects. Inter-rater reliability revealed reduced reliability in ICCagreement and in Fleiss' kappa. Percent agreement revealed satisfactory agreements when differentiating between 'poor' and 'sufficient' quality). CONCLUSION: The AQTT demonstrated high face, content and construct validity, satisfactory test-retest reliability, reduced inter-rater reliability, but satisfactory percent agreement when differentiating between 'poor' and 'sufficient' quality. The AQTT was found feasible and clinically relevant for assessing the quality of GP- and nurse-led OOH-TT. KEYPOINTS Comparative knowledge is sparse regarding quality of out-of-hours telephone triage conducted by general practitioners and nurses. The assessment tool (AQTT) enables assessment of quality in OOH telephone triage conducted by nurses and general practitioners AQTT is feasible and clinically relevant for assessment of communication, patient safety and efficiency. AQTT can be used to identify areas for improvement in telephone triage.

A primary healthcare-based intervention to improve a Danish cervical cancer screening programme: a cluster randomised controlled trial.

BACKGROUND: The proportion of non-attenders in cervical cancer screening is high, and should be minimised. A targeted invitation to women not participating for the last 5 years in cervical screening was evaluated to determine whether it would decrease the number of these women. Increasing general practitioners' attention to the screening programme for cervical cancer was also evaluated to determine whether it would increase participation. METHODS: A cluster randomised controlled trial conducted in the county of Aarhus, Denmark. All women registered with a GP were randomised. Regardless of group allocation, all women received a normal invitation. In the intervention arm, GPs were visited to facilitate quality enhancements of the screening programme, combined with a special targeted invitation to women aged 23-59 registered with the GP but not attending screening for the last 5 years. The main outcome was the proportion of non-attenders and the secondary outcome was coverage rate. RESULTS: 117 129 women registered with 190 GPs were included in the study. 1737 non-attenders had a Papanicolaou smear during follow-up. The decline in non-attenders was 0.87% (95% CI 0.57% to 1.16%) after 9 months in favour of the intervention. A difference of 0.94% (95% CI 0.21% to 1.67%) in the change of coverage rate was observed at 6 months, which increased to 1.97% (95% CI 0.03% to 3.91%) at 9 months in favour of the intervention. CONCLUSION: It is possible to decrease the proportion of non-attenders and increase the coverage rate in a screening programme for cervical cancer using a special targeted invitation to non-attenders combined with a visit to GPs. To further improve participation, other barriers must be identified and addressed.

Use and validation of public data files for identification of the diabetic population in a Danish county.

INTRODUCTION: This study aims to describe the process of identifying people known to have diabetes through public data files, to validate this method, and to describe models for optimization of such identification processes. PATIENTS AND METHODS: In a study population of 303,250 citizens, the diabetics were identified by combining information from public data files with information from general practitioners. Data validity was checked by comparing the results of data searches in public data files against information from general practitioners and a random sample of diabetics. Two models were defined to optimize the use of public data files for identification of diabetics. In model A the minimum number of parameters needed to obtain a sensitivity as high as possible was identified. In model B the optimal combination of parameters needed to obtain a high positive predictive value combined with a high sensitivity was identified. RESULTS: A total of 5449 diabetics were identified. Of those 4438 (81%) were classified as Type 2 diabetics and 1011 (19%) were classified as Type 1 diabetics. The data validation revealed that one person was misclassified as a diabetic and 93 persons were misclassified as non-diabetics. In model A the identification parameters included: "prescription", "HbA1c", "chiropodist service" and "glucose service". In model B the optimal combination of parameters was identified as: minimum two HbA1c measurements, minimum one visit to a chiropodist, minimum one prescription or minimum one abnormal HbA1c during one year. CONCLUSION: Public data files are suitable for identification of both Type 1 and Type 2 diabetics. Models have been developed to identify diabetics and to promote the possibilities of long-term follow-up and quality assessment in an unselected diabetic population in a region.

HbAlc in an unselected population of 4438 people with type 2 diabetes in a Danish county.

OBJECTIVE: To describe the use and level of HbA1c in a large unselected Type 2 diabetic population in Denmark. In addition, to describe the characteristics of the patients and the general practitioners in relation to the monitoring of HbA1c. DESIGN: Data were collected from public data files for the period January 1993 to December 1997. SETTING: The County of Vejle with a background population of 342,597 citizens, 303,250 of whom were listed with participating general practitioners. PATIENTS: The Type 2 diabetic population alive and resident in the county on 1 January 1997. RESULTS: In a population of 4438 Type 2 diabetics, 73% had a minimum of one annual HbA1c measurement in 1997. No HbA1c measurement was associated with a long history of diabetes, diet treatment or old age. Poor glycaemic regulation was found in 65% of the Type 2 diabetics in 1997. Poor glycaemic regulation was associated with tablet or insulin treatment, age under 70 years and long history of diabetes. The interpractice variation was huge. CONCLUSION: The quality of HbA1c monitoring of Type 2 diabetics needs to be improved. Possibilities for improvement seem to be present.

[Quality assessment of diabetes care in a large general practice. Identification and biomedical status]. / Kvalitetsvurdering af diabetesomsorgen i en større laegepraksis. Identifikation og biomedicinsk status.

The aims of this study were to describe the diabetic population and to evaluate the routine diabetic care in one general practice. All patients with recognized diabetes were included. Information was collected from each patient's record and from patients' and doctors' questionnaire. One hundred an fourty (1.8%) of the patients had recognized diabetes and 81% of these diabetes had non-insulin-dependent diabetes (NIDDM). According to the records, HbA1c had been monitored in 85% of the NIDDM patients in the preceding year and in 76% of the IDDM patients. The corresponding figures for albuminuria were 84% vs. 76%, for S-creatinine 74% vs. 81%, for S-cholesterol 37% vs. 24%, for weight 47% vs. 43%, for blood pressure 60% vs. 48%, for foot care 67% vs. 62% and for eye examination 76% vs. 75%. International targets for good control were obtained for HbA1c in 42% of cases, for weight in 23%, for blood pressure in 30% and for S-cholesterol in 40% at the last control. The results of the study indicate that there is a continuous demand for quality monitoring and improvement of diabetic care in general practice.

The effect of reimbursement on the use of antibiotics.

OBJECTIVE: To examine the effect of a reduction on the reimbursement of drugs on the use of antibiotics by general practitioners in Denmark. DESIGN: A prospective study using a questionnaire comparing the results with a similar study 3 years before, a period with normal reimbursement. PARTICIPANTS: 553 general practitioners prescribed antibiotics for 5765 patients. MAIN OUTCOME MEASURE: Number of treated patients and choice of antibiotics. RESULTS: 7607 patients were treated in 1987 compared with 5765 in 1990, the relative number of patients treated for sinusitis, other upper respiratory tract infections, acute bronchitis, pneumonia and upper gynaecological infections was significantly less in 1990 than in 1987. Other infections, particularly those that are often diagnosed by culture or microscopy by the general practitioners themselves, increased significantly. They included tonsillitis and urinary tract infections. CONCLUSION: Reimbursement can be a very powerful tool controlling the use of antibiotics by general practitioners.

Vaginal discharge in general practice--women's perceptions, beliefs and behaviour.

OBJECTIVES: To describe women's perceptions and beliefs about their vaginal secretion and to relate these to their behaviour with respect to complaints of vaginal discharge. DESIGN: A multi-practice study including questionnaires for women and doctors and a semi-structured interview study. SETTING: North Jutland County and Aarhus County, Denmark. SUBJECTS: 283 women with and 417 women without complaints of vaginal discharge answered a questionnaire about their vaginal secretion. Ten women with vaginal discharge took part in the in-depth interviews. RESULTS: 179/274 (65%) women with and 111/417 (27%) women without complaints of vaginal discharge were bothered by their usual secretion. In 54/269 (20%) women with complaints, the pelvic examination was normal. In 59/416 (14%) women without complaints, the doctor found an abnormal vaginal secretion. Most women complaining of vaginal discharge had an external locus of control in relation to their symptoms, but an internal locus of control in relation to health in general. Fear of having a serious disease or a sexually transmitted disease was the reason for the visit to the general practitioner in 164/281 (58%). CONCLUSION: Women's perceptions and beliefs about their vaginal secretion varied and were related to their health seeking behaviour. In addition to information about possible biological causes of vaginal discharge, the general practitioner should also actively seek information about the women's perception of normality and beliefs in relation to the symptoms she experiences.

Changes in prescription of antibiotics in general practice in relation to different strategies for drug information.

The worldwide use of antibiotics is increasing with increasing costs and resistant bacteria as a consequence. The Danish use of antibiotics is one of the lowest in DDD/1,000 inhabitants/year; however, the use of ampicillin and co-trimoxazole has been found to be too high. An information campaign in the beginning of 1987, using written material, stressed the importance of reducing the ampicillin and co-trimoxazole and increasing the penicillin usage in Denmark. This campaign was followed up by 10 lectures given by the same person in two (I and II) of the five counties of Zealand, Denmark. In county I, the lectures were given in meetings arranged by the local department of clinical microbiology. In county II, the lectures were given at meetings sponsored by a pharmaceutical company. The prescribing habits were generally changed significantly. In county I, the changes were significantly higher compared with counties only receiving written material. In county II, the prescribing habits did not change further compared with the counties only receiving written material. It is concluded that face-to-face information can improve the efficacy of written information, but sponsorship by pharmaceutical companies may weaken this efficacy.

Metronidazole pessaries compared with placebo in the treatment of bacterial vaginosis.

In a randomized, double-blind clinical trial from general practice, 500 mg metronidazole pessaries applied once daily for seven days were compared with placebo in the treatment of bacterial vaginosis. Seventy-five women completed the study. At the follow-up visit immediately after completion of treatment, none of the patients on metronidazole fulfilled the criteria for bacterial vaginosis, compared with 12 (35%) in the placebo group (p less than 0.001). Nine (22%) of the patients treated with metronidazole harboured Gardnerella vaginalis after treatments, compared with 31 (91%) in the placebo group (p less than 0.001). Symptoms had improved or disappeared in 33 (80%) on metronidazole, and in 18 (53%) on placebo therapy (p less than 0.05). Four weeks after the follow-up visit, symptoms were reported by 28% in the metronidazole group and by 44% in the placebo group (p greater than 0.05). Metronidazole pessaries are effective in the treatment of bacterial vaginosis.

Single-dose 500-mg clotrimazole vaginal tablets compared with placebo in the treatment of Candida vaginitis.

In a double-blind controlled clinical trial, 29 practitioners randomized 55 women with culture-proven Candida vaginitis to treatment with single-dose 500-mg clotrimazole vaginal tablets, and 40 to placebo. At a follow-up visit 7 to 10 days after treatment, Candida was present in 21 (38%) of those treated with clotrimazole and in 30 (75%) in the placebo group (P less than .05). Symptoms had improved or disappeared in 38 (69%) treated with clotrimazole, compared with 22 (55%) in the placebo group (P greater than .05). In 10 (23%) of the mycologically cured women, symptoms were unchanged or worse, whereas symptoms had improved or disappeared in 26 (51%) in whom Candida was isolated at the follow-up visit (P = .015). Questionnaires sent to the 95 women 4 weeks after the follow-up visit were returned by 62. Vaginal symptoms were reported by 50% in both groups. Further clinical trials including placebo are needed in general practice in the evaluation of the treatment of Candida vaginitis.

Predictors of Chlamydia trachomatis infection in women in general practice.

The purpose of this study was to identify predictors of infection with Chlamydia trachomatis in order to suggest indications for culture among women in general practice. In a multi-practice study 29 general practitioners examined 352 women complaining of vaginal discharge and 225 women having a pelvic examination for other reasons. Information from patient history, pelvic examination, and laboratory tests was recorded, and a culture for C. trachomatis was performed. C. trachomatis was isolated from 30 women (8.5%) with complaints of vaginal discharge and from nine (4.0%) without complaints. The predictive value for chlamydial infection of the information obtained was examined by logistic regression. Complaints of vaginal discharge, age under 25 years, use of oral contraception, suspected exposure to sexually transmitted disease, increased amount of discharge on pelvic examination, pH of discharge above 5.0 and the presence of leucocytes on wet smear microscopy were predictive of infection with C. trachomatis. Using information from patient history alone it was possible to discriminate between patients with low and high risk for chlamydia infection, the range being from 2% to 37%. Indications for culture for C. trachomatis, based upon easily obtained information from the patient history, are suggested.

An information campaign--an important measure in controlling the use of antibiotics.

Denmark is one of the countries using the smallest quantity of antibiotics in proportion to its population. Nevertheless, the use of ampicillin and co-trimoxazole has been found to be undesirably high. An information campaign was carried out to reduce the ampicillin and co-trimoxazole usage and to increase the penicillin usage as a consequence. To evaluate the efficacy of the campaign 602 general practitioners participated in the study, and the antibiotic treatment of 7607 patients, treated in week 13 in 1987, was recorded. These prescriptions were compared with the prescriptions recorded in two previous but identical investigations in 1979 and in 1983. The prescribing habits had changed significantly after the information campaign, resulting in national savings of two million Danish kroner/million inhabitants/year. Information could be an important measure in controlling the worldwide use of antibiotics.

Vaginal microbial flora in women with and without vaginal discharge registered in general practice.

To compare the microbiological findings for patients with and without vaginal discharge, 29 general practitioners registered 361 women with and 229 women without complaints of vaginal discharge in a multi-practice study in the county of Aarhus, Denmark. In five of the patients (1.4%) with vaginal discharge, Neisseria gonorrhoeae was isolated compared with one (0.4%) in women without vaginal discharge. Chlamydia trachomatis was isolated in 30 (8.3%) and nine (3.9) respectively, Candida in 113 (31.3%) and 44 (19.2%), Gardnerella vaginalis in 187 (51.8%) and 93 (40.6%), and Trichomonas vaginalis in 10 (2.8%) and one (0.4%). The criteria of bacterial vaginosis were fulfilled by 129 (35.7%) women with vaginal discharge, and by 19 (8.3%) without symptoms. Except for T. vaginalis and N. gonorrhoeae, the microorganisms were significantly (p less than 0.05) more frequent among patients with than without vaginal discharge. C. trachomatis was found in 25 (11%) women under the age of 25, compared to 14 (4%) aged 25 years or older (p less than 0.01). The isolation rates of the other microorganisms were not related to age. G. vaginalis was found in high concentrations in 73% of those harbouring this bacterium. No difference in concentration was found between women with and without vaginal discharge (p less than 0.05).

The diagnosis of candida vaginitis in general practice.

In a multi-practice study, 29 general practitioners registered 361 women with increased vaginal discharge, malodour, or pruritus, and 229 women without vaginal complants. A wet-smear was examined for Candida by the general practitioner. Culture for Candida was performed in the general practitioner's laboratory, and at a microbiological laboratory. Candida was found by microscopy or culture in 140 (39%) women with vaginal symptoms, compared with 51 (22%) without vaginal complaints (p less than 0.001). In 34 women with symptoms (24%) Candida was found by wet-smear microscopy, in 98 (76%) by microscopy or culture in the general practitioner's laboratory, and in 126 (90%) by microscopy or culture at the microbiological laboratory. No relation was found between the number of Candida isolated and the presence of vaginal symptoms (p greater than 0.05). The sensitivity of microscopy was low compared with previous studies and underlines the need for multi-practice studies in the evaluation of diagnostic procedures. Vagicult is recommended for general practice, but problems exist in the interpretation of a positive culture result.

Use of antibiotics in general practice in Denmark in 1987.

The worldwide usage of antibiotics is increasing making detailed information on prescribing patterns and intervention methods necessary. This investigation focused on the general practitioner's (GP's) usage of antibiotics in Denmark. Information on 7,607 patients treated by 602 GP's during 1 week in March 1987 were collected. The most commonly treated infectious diseases were upper respiratory tract infections (40%) and lower respiratory tract infections (17%). Penicillin was by far the most frequently prescribed antibiotic (44%), followed by antibiotics used locally (17%) and ampicillins (14%). Compared with previous investigations, this result indicated a relative increase in prescription of penicillin during recent years. The mean number of daily dosages was 2-3 and the duration of treatment 6-7 days, with ampicillin generally given 1 day longer than penicillin. The differences between prescribed daily dosages (PDD) found and defined daily dosages (DDD) ranged from + 40% to - 50%, making estimations of numbers of treated patients from total usage of antibiotics in DDD/1,000 inhabitants/day impossible.

Patients with vaginal discharge in general practice.

In a multi-practice study, 80 general practitioners registered 327 patients with spontaneous complaints of vaginal discharge. Forty-eight percent of the patients were between 20 and 29 years of age, compared with 20% in the general female population (p less than 0.001). An increase in discharge was reported by 89% of the women, itching by 53%, and malodour by 38%. More than one symptom was reported by 61%. The symptoms present were mutually independent and no correlation was found with age. Seventy-six percent of women 25 years or older had had earlier instances of vaginal discharge. In patients aged 15-19, 60% had experienced earlier episodes. Male consort symptoms were reported by 14% of patients less than 25 years old and by 7% of the patients 25 years or older (p less than 0.05). Symptoms had persisted for one week or less in 36% of the women, for between 1 and 2 weeks in 27%, and for more than one year in 5%.

Variation in use of penicillin for treatment of sinusitis in general practice.

The present study describes the use of phenoxymethylpenicillin and broad-spectrum penicillin for the treatment of sinusitis in general practice, in relation to some variables related to the prescribing doctors: region (county), practice form (single-handed or partnership), and the doctors' seniority (year of graduation). Log-linear analysis was used to make it possible to evaluate the influence of single factors. There was considerable variation between the counties included in the study. Practitioners in partnership practices used phenoxymethylpenicillin more frequently and broad-spectrum penicillin less frequently in the treatment of patients with sinusitis, compared with their colleagues in single-handed practices. Younger practitioners chose broad-spectrum penicillin more frequently and phenoxymethylpenicillin less frequently than their older colleagues. The individual practitioner was rather stable in his choice of drug for the treatment of consecutive patients with the same diagnosis.