挪威综合医院非急诊入院中转诊医生和非工作时间医生的守门人作用：基于登记的观察性研究。
General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study.
机构信息
National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.
Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway.
出版信息
BMC Health Serv Res. 2019 Aug 14;19(1):568. doi: 10.1186/s12913-019-4419-0.
BACKGROUND
Primary care doctors have a gatekeeper function in many healthcare systems, and strategies to reduce emergency hospital admissions often focus on general practitioners' (GPs') and out-of-hours (OOH) doctors' role. The aim of the present study was to investigate these doctors' role in emergency admissions to somatic hospitals in the Norwegian public healthcare system, where GPs and OOH doctors have a distinct gatekeeper function.
METHODS
A cross-sectional analysis was performed by linking data from the Norwegian Patient Registry (NPR) and the physicians' claims database. The referring doctor was defined as the physician who had sent a claim for a consultation with the patient within 24 h prior to an emergency admission. If there was no claim registered prior to hospital arrival, the admission was defined as direct, representing admissions from ambulance services, referrals from nursing home doctors, and admissions initiated by in-hospital doctors.
RESULTS
In 2014 there were 497,845 emergency admissions to somatic hospitals in Norway after excluding birth related conditions. Referrals by OOH doctors were most frequent (36%), 35% were direct admissions, 28% were referred by GPs, whereas only 2% were referred from outpatient clinics or private specialists with public contract. Direct admissions were more common in central areas (45%), here GPs’ referrals constituted only 18%. The prehospital paths varied with the hospital discharge diagnosis. For anaemias, 52–56% were referred by GPs, for acute appendicitis and mental/alcohol related disorders 57% and 56% were referred by OOH doctors, respectively. For malignant neoplasms 56% and cardiac arrest 57% were direct admissions.
CONCLUSIONS
GPs or OOH doctors referred many emergencies to somatic hospitals, and for some clinical conditions GPs' and OOH doctors' gatekeeping role was substantial. However, a significant proportion of the emergency admissions was direct, and this reduces the impact of the GPs' and OOH doctors' gatekeeper roles, even in a strict gatekeeping system.
背景
在许多医疗保健系统中，初级保健医生都具有守门人的作用，而降低急诊住院人数的策略通常侧重于全科医生（GP）和非工作时间（OOH）医生的作用。本研究的目的是调查这些医生在挪威公共医疗保健系统中，在全科医生和 OOH 医生具有明确守门人作用的情况下，在急诊住院治疗中的作用。
方法
通过将挪威患者登记处（NPR）和医生报销数据库中的数据进行链接，进行了横断面分析。将转诊医生定义为在急诊入院前 24 小时内发送了与患者咨询相关的索赔的医生。如果在到达医院之前没有登记索赔，则将该入院定义为直接入院，代表来自救护车服务的入院，疗养院医生的转诊以及医院内医生发起的入院。
结果
2014 年，挪威有 497,845 例急诊入院是在排除与分娩相关的疾病后得出的。OOH 医生的转诊最为常见（36％），直接入院占 35％，GP 转诊占 28％，而只有 2％是由门诊诊所或有公共合同的私人专科医生转诊而来。中央地区的直接入院更为常见（45％），在这里，GP 的转诊仅占 18％。院前路径因医院出院诊断而异。对于贫血症，分别有 52-56％是由 GP 转诊，对于急性阑尾炎和精神/酒精相关疾病，分别有 57％和 56％是由 OOH 医生转诊。恶性肿瘤的直接入院率为 56％，心搏骤停的直接入院率为 57％。
结论
GP 或 OOH 医生将许多急诊转诊至综合医院，对于某些临床情况，GP 和 OOH 医生的守门人作用是很重要的。但是，很大一部分急诊入院是直接入院，这降低了 GP 和 OOH 医生的守门人作用的影响，即使在严格的守门人制度下也是如此。
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