What if something happens tonight? A qualitative study of primary care physicians’ perspectives on an alternative to hospital admittance

Abstract

Background Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians’ (PCPs’) perspectives on admission to a MAW as an alternative to hospitalisation. Methods The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach. Results The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients’ condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients’ and relatives’ participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients’ wishes conflicted with what PCPs considered professionally sound. Conclusions The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.

Finding good alternatives to hospitalisation: a data register study in five municipal acute wards in Norway

“…Thus, the MAW appears to represent an intermediate unit rather than an alternative to the hospital. This is supported by studies claiming that the MAW represents an additional health service to already existing services [ 12 , 14 , 19 ]. Originally, the intention of the MAW was to establish an alternative to hospitalisation, particularly suitable for patients with a clarified condition or an acute deterioration of an already known condition.…”

“…The extended diagnostics in hospital was used for one out of ten patients. The extended diagnostics service has become a better-known opportunity for clinicians to ensure that patients admitted to the MAW receive the right diagnosis; that is, the use of X-rays, laboratory tests and specialist assessment by hospital physicians are assumed to give the patients a more clarified diagnosis [ 7 , 12 ]. However, most patients in MAWs are old, with a high degree of frailty [ 12 , 19 ].…”

Hospital physicians’ experiences and reflections on their work and role in relation to older patients’ pathways - a qualitative study in two Norwegian hospitals

“…nurses, physicians), a division between specialist and generalist services (e.g. two governmental levels), as well as an uncertainty related to who is responsible for the patient [ 19 – 21 ].…”

“…Earlier studies have explored primary healthcare professionals’ perspectives on older patients’ pathways within the healthcare system [ 21 , 25 , 26 ]. A qualitative study that included primary care nurses’ and hospital physicians’ perspectives on the transition from hospital to home concluded that effective communication between professionals across different healthcare institutions and different governmental levels is essential to reduce the readmission rate and improve safety and continuity of care [ 27 ].…”

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“…were forced to require GP referral to specialist healthcare services [1]. Patients in Norway who needed acute treatment but not specialty care were even transferred by primary care physicians to municipal acute wards as an alternative to hospitalization [2]. In other countries such as Japan, though patients are not forced to register with a general practitioner or family doctor, they should pay additional costs if bypassing primary care physicians and receiving care in higher-level facilities [3].…”