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1.  Could the patient have been seen by a nurse; a questionnaire based survey of GP and patient views in Danish general practice 
BMC Family Practice  2013;14:171.
Nurses in Denmark have been increasingly involved in general practice care, which may have implications for the role of the general practitioner (GP) and patients’ experience of primary care. The aim of this study was to explore possibilities of doctor-nurse substitution seen from GP and patient perspectives and patient preferences in regard to consultations with a personal GP.
The study was based on data from a Danish survey on disease patterns in general practice (KOS 2008). Background information on patients and GPs was linked with their responses to whether a nurse could have substituted the GP in consultations and patient-assessed importance of seeing a personal GP. Associations were measured with prevalence rate ratio (PR).
Doctor-nurse substitution was a possibility in 14.8% of consultations according to GPs and in 11.7% according to patients. GP and patient agreed on substitution in 3.5% of consultations (Kappa = 0.164). Follow-up consultations were more often feasible for substitution than new episode according to GPs (adj. PR = 2.06 (1.62-2.62)), but not according to patients (adj. PR = 1.02 (0.64-1.33)). Follow-up consultations were related to high importance of seeing the personal GP (adj. PR = 1.18 (1.05-1.33). For both patients and GPs, consultations with patients with chronic conditions were not significantly associated with nurse substitution. Male and younger patients did more often suggest substitution than women and older patients. For GPs, increasing patient age was associated with relevance of substitution. Patients who found it 'very important’ to see their personal GP were less likely to consider nurse substitution a possibility (adj. PR = 0.57 (0.45-0.71).
GPs and patients found nurse substitution relevant in more than one in ten consultations, although they rarely agreed on which consultations. Follow-up consultations and consultations with older patients were associated with GPs considering nurse substitution appropriate more often. For patients, male and younger patients most often found substitution relevant. High importance of seeing the personal GP may contribute to patient reluctance to nurse substitution, especially for follow-up consultations. The results indicate a need for involving patients’ perspective when altering the future roles of primary health care professionals.
PMCID: PMC3835405  PMID: 24225183
Denmark; General practice; Doctor-nurse substitution; Patients’ perspective; Chronic conditions; Follow-up consultations; Health service delivery; Patient-doctor-relationship
2.  From Doctor to Nurse Triage in the Danish Out-of-Hours Primary Care Service: Simulated Effects on Costs 
Introduction. General practitioners (GP) answer calls to the Danish out-of-hours primary care service (OOH) in Denmark, and this is a subject of discussions about quality and cost-effectiveness. The aim of this study was to estimate changes in fee costs if nurses substituted the GPs. Methods. We applied experiences from The Netherlands on nurse performance in the OOH triage concerning the number of calls per hour. Using the 2011 number of calls in one region, we examined three hypothetical scenarios with nurse triage and calculated the differences in fee costs. Results. A new organisation with 97 employed nurses would be needed. Fewer telephone consultations may result in an increase of face-to-face contacts, resulting in an increase of 23.6% in costs fees. Under optimal circumstances (e.g., a lower demand for OOH services, a high telephone termination rate, and unchanged GP fees) the costs could be reduced by 26.2% though excluding administrative costs of a new organisation. Conclusion. Substituting GPs with nurses in OOH primary care may increase the cost in fees compared to a model with only GPs. Further research is needed involving more influencing factors, such as costs due to nurse training and running the organisation.
PMCID: PMC3806230  PMID: 24194984
3.  Psychological and social problems in primary care patients - general practitioners’ assessment and classification 
Objective. To estimate the frequency of psychological and social classification codes employed by general practitioners (GPs) and to explore the extent to which GPs ascribed health problems to biomedical, psychological, or social factors. Design. A cross-sectional survey based on questionnaire data from GPs. Setting. Danish primary care. Subjects. 387 GPs and their face-to-face contacts with 5543 patients. Main outcome measures. GPs registered consecutive patients on registration forms including reason for encounter, diagnostic classification of main problem, and a GP assessment of biomedical, psychological, and social factors’ influence on the contact. Results. The GP-stated reasons for encounter largely overlapped with their classification of the managed problem. Using the International Classification of Primary Care (ICPC-2-R), GPs classified 600 (11%) patients with psychological problems and 30 (0.5%) with social problems. Both codes for problems/complaints and specific disorders were used as the GP's diagnostic classification of the main problem. Two problems (depression and acute stress reaction/adjustment disorder) accounted for 51% of all psychological classifications made. GPs generally emphasized biomedical aspects of the contacts. Psychological aspects were given greater importance in follow-up consultations than in first-episode consultations, whereas social factors were rarely seen as essential to the consultation. Conclusion. Psychological problems are frequently seen and managed in primary care and most are classified within a few diagnostic categories. Social matters are rarely considered or classified.
PMCID: PMC3587306  PMID: 23281962
Classification; Denmark; diagnosis; general practice; ICPC; mental disorders; primary health care; social problems
4.  Chronic care management in Danish general practice - a cross‒sectional study of workload and multimorbidity 
BMC Family Practice  2012;13:52.
About 30% of the Danish population has one or more chronic conditions, and general practitioners (GPs) play a key role in effective chronic care management. However, little is known about these encounters in general practice. The aim was to describe the frequency of patients with one or more chronic conditions in general practice and how these consultations were experienced by the GPs.
All GPs in the Central Denmark Region were invited to register all contacts during one day in the 12‒month study period from December; 404 (46%) accepted. For each patient contact, the GPs were asked to fill in a one‒page registration form covering information on chronic disease, reason for encounter, diagnosis, number of additional psychosocial problems raised by the patient during the consultation, time consumption, experienced burden of the consultation, referral to specialized care, and whether a nurse could have substituted the GP. Patients were categorized according to the number of chronic conditions (none, one, two, three or more) and the categories compared with regard to the GP‒experienced burden of the contacts. Moreover, we examined which chronic conditions posed the the greatest challenge to the GPs.
Patients aged 40 years or more had a total of 8,236 contacts. Among these patients 2,849 (34.6%; 95% CI 33.6‒35.6) had one and 2,596 (31.5%; CI 30.5‒32.5) had more than one chronic disease. The time consumption and the burden of their contacts tended to rise with the number of chronic conditions. Being present in 22.9% (CI 21.6‒24.3) of all face‒to‒face contacts, hypertension was the most common chronic condition. The burden of the contacts was experienced as particularly heavy for patients with depression and dementia due to more additional psychosocial problems and the time consumption.
General practitioners considered consultations with multimorbid patients demanding and not easily delegated to nurses. As the number of patients with chronic conditions and multimorbidity is increasing, GPs can be expected to face a heavier workload in the future.
PMCID: PMC3436724  PMID: 22676446
Primary care; Chronic disease; Multimorbidity; Workload
5.  Reasons for encounter and disease patterns in Danish primary care: Changes over 16 years 
Approximately 98% of Danish citizens are listed with a general practice which they consult for medical advice. Although 85% of the population contact their general practitioner (GP) every year, little is known about these contacts. The aim of the present paper is to gain updated knowledge about patients’ reasons for encounter and the GP activities and to make comparisons with a similar study from 1993.
All GPs in the Central Denmark Region were invited to register all contacts during one randomly chosen day within a year. The registration included questions about patients’ reasons for encounter, the types and contents of the contacts, referrals, and distribution between new episodes and follow-up contacts. Aggregated data were compared with the results from 1993.
A total of 404 (46%) GPs participated. The number of contacts per 1000 inhabitants had risen by 19.7%. The reasons for encounter and final diagnoses resembled those in 1993. Musculoskeletal, psychological, and respiratory problems were the most common reasons for encounter, psychological problems being the only type to increase over the period. Interestingly, the proportion of diagnoses within the ICPC ‘A’ chapter rose from 13.5 to 19.7%. The referral rate rose by 2% (relative: 18.7%) from 10.7% to 12.7% and the share of follow-up contacts rose from 45.9% to 50.4% (relative: 8.7%).
Quite small changes were seen in the patterns of reasons for encounter and diagnoses from 1993 to 2009. However, an increase was found in contacts with general practice and referrals and in the proportion of follow-ups.
PMCID: PMC3378007  PMID: 22643150
Denmark; diagnoses; general practice; reasons for encounter; referral rate
6.  Diagnostic scope in out-of-hours primary care services in eight European countries: an observational study 
BMC Family Practice  2011;12:30.
In previous years, out- of-hours primary care has been organised in large-scale organisations in many countries. This may have lowered the threshold for many patients to present health problems at nights and during the weekend. Comparisons of out-of-hours care between countries require internationally comparable figures on symptoms and diagnoses, which were not available. This study aimed to describe the symptoms and diagnoses in out-of-hours primary care services in regions in eight European countries.
We conducted a retrospective observational study based on medical records from out-of-hours primary care services in Belgium, Denmark, Germany, the Netherlands, Norway, Slovenia, Spain, and Switzerland. We aimed to include data on 1000 initial contacts from up to three organisations per country. Excluded were contacts with an administrative reason. The International Classification for Primary Care (ICPC) was used to categorise symptoms and diagnoses. In two countries (Slovenia and Spain) ICD10 codes were translated into ICPC codes.
The age distribution of patients showed a high consistency across countries, while the percentage of males varied from 33.7% to 48.3%. The ICPC categories that were used most frequently concerned: chapter A 'general and unspecified symptoms' (mean 13.2%), chapter R 'respiratory' (mean 20.4%), chapter L 'musculoskeletal' (mean 15.0%), chapter S 'skin' (mean 12.5%), and chapter D 'digestive' (mean 11.6%). So, relatively high numbers of patients presenting with infectious diseases or acute pain related syndromes. This was largely consistent across age groups, but in some age groups chapter H ('ear problems'), chapter L ('musculoskeletal') and chapter K ('cardiovascular') were frequently used. Acute life-threatening problems had a low incidence.
This international study suggested a highly similar diagnostic scope in out-of-hours primary care services. The incidence rates of acute life-threatening health problems were low in all countries.
PMCID: PMC3114765  PMID: 21569483
primary health care; after-hours care; diagnosis
7.  A Danish population-based cohort study of newly diagnosed asthmatic children's care pathway – adherence to guidelines 
Asthma is the most common chronic disease in childhood. Large variations exist concerning the number of children being treated by general practitioners and by specialists. Consequently, health related costs due to this disease vary as care by specialists is more expensive compared with care by general practitioners. Little is known of the consequences of these variations concerning the quality of care. The aim of the study was to analyse associations between care providers and adherence to guidelines concerning frequency of contacts with the health service due to asthma.
A cohort study was performed of 36,940 incident asthmatic children's (aged 6–14) contacts with the health service using the unique personal registration number to link data from five national registries. The prevalence ratios were calculated for associations between provider (general practitioner, primary care specialist, hospital specialist or both GP and specialist) and adherence with guidelines concerning three indicators of quality of care pathway: 1) diagnostic examination of lung function at start of medical treatment 2) follow-up the first six months and 3) follow-up the next six months. The associations were adjusted for sex, age, socioeconomic status, county, and severity of disease.
Most children (70.3%) had only been seen by their GP. About 80% of the children were treated with inhaled steroids, 70% were treated with inhaled steroids as well as inhaled beta2agonists and 13% were treated with inhaled beta2agonists only. A total of 12,650 children (34.2%) had no registered asthma-related contacts with the health service except when redeeming prescriptions. Care was in accordance with guidelines in all three indicators of quality in 7% of the cases (GPs only: 3%, primary care specialists only: 16%, hospital specialists: 28%, and both GP and specialists: 13%). Primary care specialists had a 5.01, hospital specialists a 8.81 and both GP and specialists a 4.32 times higher propensity to provide a clinical pathway according to guidelines compared to GPs alone.
The majority of the children were seen in general practice. Hospital specialists provided care in accordance with guidelines nine times more often compared with GPs, but still only one quarter of these children had pathways in accordance with guidelines. It is relevant to study further if these lacks of adherence to guidelines have implications for the asthmatic children or if guidelines are too demanding concerning frequency of follow-up or if asthmatic children should be stratified to different care pathways.
PMCID: PMC2440738  PMID: 18549494

Results 1-7 (7)