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ObjectivesAcute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children.DesignSecondary analysis of a randomised controlled study.Setting4 out-of-hours services and 1 paediatric emergency clinic in Norwegian primary care.Participants401 children aged 0–6 years with respiratory symptoms and/or fever visiting the out-of-hours services.Outcomes2 main outcome variables were registered: antibiotic prescription and referral to hospital.ResultsThe total prescription rate of antibiotics was 23%, phenoxymethylpenicillin was used in 67% of the cases. Findings on ear examination (OR 4.62; 95% CI 2.35 to 9.10), parents' assessment that the child has a bacterial infection (OR 2.45; 95% CI 1.17 to 5.13) and a C reactive protein (CRP) value >20 mg/L (OR 3.57; 95% CI 1.43 to 8.83) were significantly associated with prescription of antibiotics. Vomiting in the past 24 hours was negatively associated with prescription (OR 0.26; 95% CI 0.13 to 0.53). The main predictors significantly associated with referral to hospital were respiratory rate (OR 1.07; 95% CI 1.03 to 1.12), oxygen saturation <95% (OR 3.39; 95% CI 1.02 to 11.23), signs on auscultation (OR 5.57; 95% CI 1.96 to 15.84) and the parents' assessment before the consultation that the child needs hospitalisation (OR 414; 95% CI 26 to 6624).ConclusionsCRP values >20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents' assessment was also significantly associated with the outcomes.Trial registration numberNCT02496559; Results.

Objective We examined the association of outdoor air pollution and meteorological parameters with primary care visits (PCVs) at night due to asthma attack. Setting A case-crossover study was conducted in a primary care clinic in Himeji City, Japan. Participants Participants were 1447 children aged 0–14 years who visited the clinic with an asthma attack from April 2010 until March 2013. Exposure Daily concentrations of air pollutants and meteorological parameters were measured. Primary outcome PCVs at night due to asthma attack. A conditional logistic regression model was used to estimate ORs of PCVs per unit increment of air pollutants or meteorological parameters (the per-unit increments of particulate matter with an aerodynamic diameter ≤2.5 µm (PM2.5) and ozone were 10 μg/m3 and 10 ppb, respectively). Analyses took into consideration the effects of seasonality. Results We noted an association between PCVs and daily ozone levels on the day before a PCV (OR=1.17; 95% CI 1.01 to 1.35; p=0.04), as well as between PCVs and 3-day mean ozone levels before a PCV (OR=1.29; 95% CI 1.00 to 1.46; p=0.04), from April until June. We also observed an association between PCVs and daily PM2.5 levels on the day before a PCV from December until March (OR=1.16; 95% CI 1.01 to 1.33; p=0.05). Meteorological parameters, such as hours of sunshine from September until November, atmospheric pressure from April until June, and temperature from April until August, were also found to be associated with PCVs. Conclusions The findings in the present study supported an association between ozone and PCVs and suggest that certain meteorological items may be associated with PCVs.

Background Low socioeconomic status (SES) is persistently associated with poor health and suboptimal use of healthcare services, and more unplanned healthcare use. Suboptimal use of emergency and acute healthcare services may increase health inequalities, due to late diagnosis or lack of continuity of care. Given that health literacy has been associated with healthcare utilisation and with education attainment, we sought to explore whether health literacy is related to the use of out-of-hours (OOH) Primary Care Services (PCSs). Additionally, we aimed to study whether and to what extent health literacy accounts for some of the association between education and OOH PSC use. Methods A survey including measures of education attainment, health literacy (assessed by means of the Dutch version of the nine-dimension Health Literacy Questionnaire) and use of PCS was conducted among a sample of adults diagnosed with (any) somatic chronic condition in the Netherlands (response 76.3%, n  = 1811). We conducted linear and logistic regression analyses to examine associations between education level and PCS use in the past year. We performed mediation analyses to assess whether the association between education and PCS use was (partly) explained by different aspects of health literacy. We adjusted the models for patient characteristics such as age and morbidity. Results Higher education attainment was associated with higher scores on the health literacy aspects Appraisal of health information, and Navigating the healthcare system. Additionally, appraisal and navigating the healthcare system partially accounted for educational differences in PCS use. Finally, higher appraisal of health information scores were associated with higher PCS utilisation. Conclusion Several aspects of health literacy were demonstrated to relate to PCS use, and partly accounted for educational differences herein. Accordingly, developing health literacy within individuals or communities may help to reduce inappropriate PCS use among people with low education.

Weekend hospital admission is associated with increased mortality, but the contributions of varying illness severity and admission time to this weekend effect remain unexplored. We analysed unselected emergency admissions to four Oxford University National Health Service hospitals in the UK from Jan 1, 2006, to Dec 31, 2014. The primary outcome was death within 30 days of admission (in or out of hospital), analysed using Cox models measuring time from admission. The primary exposure was day of the week of admission. We adjusted for multiple confounders including demographics, comorbidities, and admission characteristics, incorporating non-linearity and interactions. Models then considered the effect of adjusting for 15 common haematology and biochemistry test results or proxies for hospital workload. 257 596 individuals underwent 503 938 emergency admissions. 18 313 (4·7%) patients admitted as weekday energency admissions and 6070 (5·1%) patients admitted as weekend emergency admissions died within 30 days (p<0·0001). 9347 individuals underwent 9707 emergency admissions on public holidays. 559 (5·8%) died within 30 days (p<0·0001 vs weekday). 15 routine haematology and biochemistry test results were highly prognostic for mortality. In 271 465 (53·9%) admissions with complete data, adjustment for test results explained 33% (95% CI 21 to 70) of the excess mortality associated with emergency admission on Saturdays compared with Wednesdays, 52% (lower 95% CI 34) on Sundays, and 87% (lower 95% CI 45) on public holidays after adjustment for standard patient characteristics. Excess mortality was predominantly restricted to admissions between 1100 h and 1500 h (pinteraction=0·04). No hospital workload measure was independently associated with mortality (all p values >0·06). Adjustment for routine test results substantially reduced excess mortality associated with emergency admission at weekends and public holidays. Adjustment for patient-level factors not available in our study might further reduce the residual excess mortality, particularly as this clustered around midday at weekends. Hospital workload was not associated with mortality. Together, these findings suggest that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services. NIHR Oxford Biomedical Research Centre.

BACKGROUND:An association between weekend health care delivery and poor outcomes has become known as the “weekend effect.” Evidence for such an association among surgery patients has not previously been synthesized. OBJECTIVE:To systematically review associations between weekend surgical care and postoperative mortality. METHODS:We searched PubMed, EMBASE, and references of relevant articles for studies that compared postoperative mortality either; (1) according to the day of the week of surgery for elective operations, or (2) according to weekend versus weekday admission for urgent/emergent operations. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for postoperative mortality (≤90 d or inpatient mortality) were pooled using random-effects models. RESULTS:Among 4027 citations identified, 10 elective surgery studies and 19 urgent/emergent surgery studies with a total of >6,685,970 and >1,424,316 patients, respectively, met the inclusion criteria. Pooled odds of mortality following elective surgery rose in a graded manner as the day of the week of surgery approached the weekend [Monday OR=1 (reference); Tuesday OR=1.04 (95% CI=0.97–1.11); Wednesday OR=1.08 (95% CI=0.98–1.19); Thursday OR=1.12 (95% CI=1.03–1.22); Friday OR=1.24 (95% CI=1.10–1.38)]. Mortality was also higher among patients who underwent urgent/emergent surgery after admission on the weekend relative to admission on weekdays (OR=1.27; 95% CI=1.08–1.49). CONCLUSIONS:Postoperative mortality rises as the day of the week of elective surgery approaches the weekend, and is higher after admission for urgent/emergent surgery on the weekend compared with weekdays. Future research should focus on clarifying underlying causes of this association and potentially mitigating its impact.

PurposeDischarge from an intensive care unit (ICU) out of hours is common. We undertook a systematic review and meta-analysis to explore the association between time of discharge and mortality/ICU readmission.MethodsWe searched Medline, Embase, Web of Knowledge, CINAHL, the Cochrane Library and OpenGrey to June 2017. We included studies reporting in-hospital mortality and/or ICU readmission rates by ICU discharge “out-of-hours” and “in-hours”. Inclusion was limited to patients aged ≥ 16 years discharged alive from a non-specialist ICU to a lower level of hospital care. Studies restricted to specific diseases were excluded. We assessed study quality using the Newcastle Ottowa Scale. We extracted published data, summarising using a random-effects meta-analysis.ResultsOur searches identified 1961 studies. We included unadjusted data from 1,191,178 patients from 18 cohort studies (presenting data from 1994 to 2014). “Out of hours” had multiple definitions, beginning between 16:00 and 22:00 and ending between 05:59 and 09:00. Patients discharged out of hours had higher in-hospital mortality [relative risk (95% CI) 1.39 (1.24, 1.57) p < 0.0001] and readmission rates [1·30 (1.19, 1.42), p < 0.001] than patients discharged in hours. Heterogeneity was high (I2 90.1% for mortality and 90.2% for readmission), resulting from differences in effect size rather than the presence of an effect.ConclusionsOut-of-hours discharge from an ICU is strongly associated with both in-hospital death and ICU readmission. These effects persisted across all definitions of “out of hours” and across healthcare systems in different geographical locations. Whether these increases in mortality and readmission result from patient differences, differences in care, or a combination remains unclear.

IntroductionAfter a child is discharged home following an emergency admission to hospital, little is known about contact with emergency departments (ED) or out-of-hours (OOH) general practice. Here, we report the number of contacts with ED and OOH in the week after discharge from hospital in Scotland during 2015–2017, including the number of contacts which result in a readmission.MethodsDatabases containing routinely collected details from hospital admissions for an acute medical condition and subsequent presentation to ED or OOH were linked using a unique personal identifier and the date of discharge.ResultsOf 171 039 urgent admissions, the source of referral was identified for 97 177 (57%) including 92 148 referred by ED or OOH. In the week following discharge, 11 025 (11%) children had a total of 11 497 contacts with ED and/or OOH. The daily number of contacts with ED and/or OOH fell from 2560 on the day after discharge to 1008 1 week after discharge. There were 3892 (35%) children readmitted following contact with ED and/or OOH. An additional 7133 children had a total of 7605 contacts with ED and/or OOH in the week postdischarge but were not readmitted.ConclusionMany families seek medical assistance for their child from ED and/or OOH in the week after discharge from hospital, and the majority are not managed by or referred back to paediatric services. Clearer discharge planning could reduce the burden on ED, OOH and parents.

Community-based out-of-hours services are an integral component of end-of-life care. However, there is little understanding of how patients and families utilise these services. This additional analysis of a systematic review aims to understand and identify patterns of out-of-hours service use and produce recommendations for future service design. Data on service use was extracted and secondary analysis undertaken, from a systematic review of models of community out-of-hours services. Narrative synthesis was completed, addressing four specific aspects of service use: 1.Times when patients/families/healthcare professionals need to contact out-of-hours services; 2. Who contacts out-of-hours services; 3. Whether a telephone call, centre visit or home visit is provided; 4. Who responds to out-of-hours calls. Community-based out-of-hours palliative care services were most often accessed between 5pm and midnight, especially on weekdays (with reports of 69% of all calls being made out-of-hours). Family members and carers were the most frequent callers to of the services (making between 60% and 80% of all calls). The type of contact (telephone, centre visit or home visit) varied based on what was offered and on patient need. Over half of services were led by a single discipline (nurse). Out-of-hours services are highly used up to midnight, and particularly by patients' family and carers. Recommendations to commissioners and service providers are to: • Increase provision of out-of-hours services between 5pm and midnight to reflect the increased use at these times. • Ensure that family and carers are provided with clear contact details for out-of-hours support. • Ensure patient records can be easily accessed by health professionals responding to calls, making the triage process easier. • Listen to patients, family and carers in the design of out-of-hours services, including telephone services. • Collect data systematically on out-of-hours-service use and on outcomes for patients who use the service.

Purpose Care home residents often suffer from several morbidities, including dementia, and are prone to acute hospital admissions. Attempts to reduce avoidable hospitalisations from care homes are diverse, but they can include a strengthened collaboration between care home facilities and primary care physicians (PCPs). We aim to investigate whether residents of care homes with and without a care home physician have different contact patterns with PCPs, out-of-hours service, and hospitals. Methods Retrospective register-based study combined data from the Danish national health registries with information from a telephone interview, obtaining information on the care homes’ collaboration with local PCPs. Care homes were divided into two groups: Facilities with ( n  = 26) and without ( n  = 10) a care home physician in 2019. We used Quasi-Poisson regression to analyse whether residents of facilities with and without a care home physician had a similar pattern for contacts with PCPs, the out-of-hours service, and hospitals. Results Residents of facilities with a care home physician ( n  = 1,368) had more than twice as many home visits by the PCP and 37% fewer e-mail consultations when compared to residents of facilities with no care home physician ( n  = 500). They tended to have fewer contacts with the out-of-hours service, but this result was not significant. We found no differences in the use of hospital services. Conclusion We saw an increased availability of PCPs in care homes with a care home physician and lower use of the out-of-hours service, but no impact on hospital admissions.

An association between weekend/off-hour care and unfavorable clinical outcomes has been observed, commonly called the \"weekend effect.\" In the present study, we examined whether there was a weekend effect associated with blood culture (BC) contamination, which can lead to inappropriate medical resource consumption. We conducted a single-center retrospective observational study using data from BC tests performed on adult patients. The primary outcome was the incidence of BC contamination, which was compared between weekend and weekday sampling groups. In a multivariable logistic analysis, we evaluated the association between weekend sampling and the incidence of BC contamination. The analysis included 7,597 weekend and 50,655 weekday BC sets from 1 January 2013 to 31 December 2019. The proportion of BC contamination during the study period was 1.15% (87/7,597) and 0.80% (405/50,655) in the weekend and weekday groups, respectively. In the logistic regression analysis adjusted for blood sampling settings, weekend sampling was significantly associated with increased BC contamination (odds ratio, 1.36; 95% confidence interval, 1.06-1.71). This study highlighted a significant association between weekend blood sampling for BC and an increased incidence of contamination. To provide better-quality care, further studies evaluating the differences in staffing and blood collection processes on weekends and weekdays are warranted.