This study shows that in Norwegian municipalities with casualty clinics in a single permanent location in 2011, increasing average travel distances were strongly associated with reduced activity at the casualty clinic as reflected in reimbursement claims submitted to HELFO. An increase in travel distances from 0 to 50 kilometres led to a 45 % reduction in the frequency of tariff codes for contacts with casualty clinics as a whole. Municipalities linked to casualty clinics located in hospitals had lower consultation rates than municipalities with casualty clinics located outside hospitals when adjusted for distance. Similarly, municipalities linked to single-municipality casualty clinics had higher consultation rates for OOH services than municipalities linked to inter-municipal casualty clinics.
The reduction in the total number of contacts, consultations and house calls was of the same magnitude as in previously reported findings from the casualty clinics included in the Watchtower project (7, 8). The observed drop in the consultation rate of 1.3 % per kilometre was somewhat lower than that in the Watchtower clinics where it amounted to 1.8 % per kilometre (8). We have previously detected a greater use of telephone consultations with an increase in distance. In the present material we cannot observe any such increase, but based on the regression analysis we rather noted a small decrease.
The findings in this study strengthen the hypothesis that travel distance is a crucial factor for utilisation of OOH services. We believe that the results emphasise the necessity of giving priority to measures that can counteract the inequalities in the utilisation of OOH services caused by distance. As in other services, also within health care, the differences can partly be explained by the fact that availability rather than real needs decides the degree of utilisation.
The observation that municipalities having casualty clinics located in an inter-municipal facility or at a hospital have lower face-to-face consultation rates when adjusted for distance can be explained by the fact that these clinics tend to be larger and more professional, and therefore better able to give priority to those patients who are in real need of emergency medical services. The threshold for contacting casualty clinics in hospitals may be higher because the population tends to see them less as part of the primary health services, or because the members of staff who receive the calls may find it easier to turn patients away due to a larger perceived distance to the callers.
Moreover, hospital-based and inter-municipal casualty clinics will often face a greater scarcity of medical resources because of their high patient load, while the lower load at single-municipality casualty clinics may give doctors a greater financial incentive to take in patients who should preferably be treated by a GP during regular office hours. In hospitals, more patients are likely to be directly admitted without first having been examined by a doctor at the casualty clinic.
Figures from the Watchtower project show that three of every four contacts in casualty clinics have a «green» degree of urgency (14), and a considerable proportion of these involve conditions that can often be handled by a GP during the daytime. We may therefore assume that the utilisation of OOH services is somewhat higher than what purely medical conditions would indicate. We believe that the results in this study indicate that the utilisation of OOH services can be reduced by municipalities joining forces in inter-municipal casualty clinics, as suggested in the action plan proposed by the National Centre for Emergency Primary Health Care from 2009 (15).
One may easily take the lower consultation rate detected in hospital-based casualty clinics as an argument for integrating emergency primary and secondary services in hospitals, similar to what is common internationally in the form of «emergency rooms» or «accident and emergency departments». We believe that the findings provide no grounds for such a conclusion. Norwegian casualty clinics are not integrated into the hospitals’ emergency wards as they tend to be in other countries. As a rule, they are co-located in separate premises as an independent organisation. Like other Norwegian casualty clinics, they have a strong basis in general-practice medicine, making them incomparable to emergency wards in other countries.
The advantages of co-location must be weighed against the risk of an increasing number of admissions. The National Centre for Emergency Primary Health Care has been sceptical to the integration of OOH services into emergency wards (so-called joint emergency wards) exactly because of the risk of weakening the casualty clinic’s function as a gatekeeper. This may lead to an increased use of resources in the hospitals and an increased use of easily available technology and diagnostic equipment on the casualty clinic’s patients – with no beneficial health effect (15).
The results from this study show that in 2011 municipalities that were linked to an inter-municipal casualty clinic based in a hospital had a 4 % higher rate of admissions than municipalities in which the casualty clinic was located outside a hospital. This difference was nevertheless far smaller than the difference in consultation rates in casualty clinics (22 %, not adjusted for distance). It is worth noting that these figures are not directly comparable, because a person is counted only once in the admissions statistics if he or she is admitted on repeated occasions with the same condition during a single year. In the KUHR database a person can be registered an unlimited number of times with the same condition.
A key strength of this study is that it retrieves data from the KUHR database, an official and objective source based on all patient contacts for which the doctor has written an electronic invoice to HELFO. The material does not include paper-based reimbursement claims and reimbursements that are paid to the patient if the doctor has no contract for direct settlement; these have been estimated to account for less than 1 % in 2010 (16). The number of reimbursement claims appears to provide a good impression of the activity in the primary health services, and the National Centre for Emergency Primary Health Care publishes annual reports on the activity in casualty clinics on the basis of such figures (16).
A majority of the country’s municipalities and inhabitants are included in the analyses presented in this study. Our data sources cannot tell us anything about the correlation between distances and utilisation of OOH services in the excluded municipalities, but we have no reason to assume that the effect will be any different there. The median population is lower in the excluded municipalities, but according to our previous studies (7, 8) the distance effect is not weaker in small municipalities.
We have previously documented that the method used for estimating average distances is at least as reliable as other standard methods when the exact addresses are unknown (8), although variations in the postcode structure may have given rise to varying levels of precision between municipalities.
Compared to the results from the studies of the municipalities included in the Watchtower project, there is a larger dispersion in the contact rates based on reimbursement claims. Part of the reason is that this study includes a higher number of municipalities, which demonstrates that Norwegian municipalities are more diverse than that indicated by the Watchtower project.
When a patient uses OOH services in another municipality, the reimbursement claim will be registered in his or her home municipality. The effect that this will have on the analysis is uncertain. We have previously shown that the casualty clinics included in the Watchtower project are used to only a small extent by the inhabitants of the neighbouring municipalities (14). Patients from abroad or from municipalities outside the OOH district accounted for 9 % of the contacts at Arendal casualty clinic in the period 2007 – 11 (7), and there is reason to assume that this proportion may be higher in other municipalities where a larger proportion of the inhabitants stay outside the municipality for longer periods of time (weekly commuters, students). Different practices for the use of tariff codes may also have an effect, for example a patient who has contacted the casualty clinic on repeated occasions can account for one or more reimbursement claims, depending on local practices.
Incorrect information in the Norwegian Emergency Primary Health Care Registry may also produce inaccuracies in the results. Even though the information stems from the OOH services themselves, we have identified a number of errors that have been corrected. We cannot exclude that certain errors have been left undiscovered in the information that we have used in our analyses regarding the organisation of OOH services.
Many comparisons have been made, and this increases the risk of false-positive results. We have not corrected for multiple testing. In this study we have only investigated co-location with hospitals and linkages to single-municipality versus inter-municipal casualty clinics. It is possible that the findings can be explained by other factors that we have not investigated. In a previous study we have shown that the utilisation of OOH services is minimally influenced by coverage of medical services, income levels, income differences, the proportion of inhabitants older than 80 and education levels when compared to geographical distance (7).
It is important to point out that the information in the management data from the KUHR database is restricted to the number of different types of contact in each municipality. In contrast to the Watchtower project there is no information on degree of urgency, age, gender or the use of ambulance transport.