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Can Fam Physician
Vol. 53, No. 3, March 2007, pp.450 - 456
Copyright © 2007 by The College of Family Physicians of Canada
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Research

Typology of after-hours care instructions for patients

Telephone survey and multivariate analysis

Risa Bordman, MD CCFP FCFP
Assistant Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario

Monica Bovett, RN
Research Assistant, is a Public Health Nurse with the Region of Peel in Ontario

Neil Drummond, PhD
Associate Professor in the Department of Family Medicine and the Departments of Family and Community Health Sciences at the University of Calgary in Alberta

Eric J. Crighton, PhD
Assistant Professor in the Department of Geography at the University of Ottawa in Ontario

David Wheler, MD CCFP
Assistant Professor in the Department of Family and Community Medicine at the University of Toronto

Rahim Moineddin, PhD
Researcher in the Department of Family and Community Medicine at the University of Toronto

David White, MD CCFP FCFP on behalf of the North Toronto Primary Care Research Network (Nortren)
Associate Professor in the Department of Family and Community Medicine at the University of Toronto

Correspondence to: Dr Risa Bordman, North York General Hospital, 4001 Leslie St, 4 S, Toronto, ON M2K 1E1; e-mail rbordman{at}rogers.com

After-hours care (AHC) is an important aspect of primary care that falls directly into the domains of continuity and comprehensiveness. Changes in AHC have been taking place throughout the developed world for more than a decade, driven by such issues as cost containment, work force morale, patients’ safety, and patients’ access to care.1–13

In Canada, Patel et al14 found that family physicians’ availability for consultation about children’s illnesses after hours in 4 major Canadian cities varied by location. (In Montreal, 28% were available; in Ottawa, 40%; in Toronto, 54%; and in Winnipeg, 87%.) An analysis of the 2001 National Family Physician Workforce Survey (NFPWS)15 found that 62% of family physicians in Canada provided AHC. This number varied by province and ranged from 34% to 88%. Updated results of the NFPWS16 indicated that at least 1 type of on-call service (eg, obstetric, emergency, inpatient) was provided by 74% of primary care physicians.

Studies have reported little evidence of differences in clinical outcomes associated with particular types of AHC, although patient satisfaction was lower in association with telephone consultations.17 In 1 study, community preference for location of AHC for children with respiratory symptoms was the hospital emergency department.18 No relationship appears to exist between cost of AHC and type or size of provider organization.19

In Toronto and surrounding area, there are several different types of AHC, such as housecall services (physicians visiting patients in their homes), walk-in clinics (no appointments, extended open hours), and after-hours clinics (open only after hours, including holidays, and usually staffed by doctors with regular practices). These new models, however, do not usually provide service after midnight, leaving emergency departments and doctors-on-call to fill the gap.

While the literature on AHC has been growing in recent years, we still do not understand enough about the types of AHC arrangements that exist and the factors that influence them. This study was designed to develop a formal typology of AHC in the context of family practice in Canada and to examine physician and practice characteristics associated with specific types of AHC instructions.


   METHODS
TOP
 METHODS
RESULTS
 DISCUSSION
 Footnotes
 Acknowledgments
 References
 
Between December 2002 and April 2003, we conducted a cross-sectional telephone survey of family physicians in the greater Toronto area. A comprehensive electronic database, the 2002 Canadian Medical Directory (non-specialist section), was used to generate an initial list of physicians and to provide demographic information on potential subjects (location, year and country of graduation, other degrees, sex, hospital affiliation, and whether they had College of Family Physicians of Canada [CFPC] Certification). Physicians who were identified as not providing general primary care or who worked part-time were removed and replaced with the next listed physician. Doctors were grouped by the first 3 digits of the postal code of their main practice address and then systematically randomized by selecting every seventh name. Based on the findings of Patel et al,14 we calculated that a minimum sample size of 384 would be required to estimate with 95% confidence and a 5% margin of error the after-hours availability of family physicians in Toronto. To ensure this minimum sample was obtained, we oversampled to allow for the exclusion of those not providing general primary care.

The practices of eligible physicians were telephoned on weekday and weekend evenings between 8:00 PM and 10:30 PM. Form of response (eg, recorded message, "live" person), content of information given, use of language other than English, and office hours (if provided) were recorded. For calls answered in person, the respondent was asked, "If I were a patient calling at this time with a medical problem, what would you tell me?" To exclude the possibility that a "no answer" response was due to a technical problem or human error (eg, forgetting to turn on an answering machine), no-response sites were called at least twice on different evenings. All physicians were called during office hours to validate their after-hours messages, confirm regular hours, verify that they were family physicians working 3 days a week or more, and record the size of the practice.

To develop the typology, 20 after-hours messages were selected at random and subjected to inductive analysis of both content and form by 3 of the researchers independently in order to develop a thematic coding schema. The 20 messages, identified themes, and coding schema were then compared by the 3 researchers together to reach consensus on the final theme list and coding schema. The research assistant then applied this schema to the complete data set. Responses that could not be readily coded were brought to the whole research group for classification by consensus. During this process, it became clear that analysis of form had less explanatory power than analysis of content, except when there was direct "voice-to-voice" contact with a physician, in which case the content of the message depended on the specific reason for the call.

Data analysis involved both univariate and multivariate logistic regression techniques. Variables that could determine choice of AHC were selected based on literature review, our pilot study, and a priori judgment. Variables that were associated with outcomes with a P value of ≤.20 in the univariate analysis were entered into multivariate logistic models. If a variable made the parameter estimates of the model unstable, it was dropped. All data manipulation and statistical analyses were carried out using SAS, version 8.2.

Ethics approval was obtained from the Research Ethics Boards of the Scarborough Hospital, Sunnybrook and Women’s College Health Sciences Centre, and North York General Hospital.


   RESULTS
TOP
 METHODS
 RESULTS
DISCUSSION
 Footnotes
 Acknowledgments
 References
 
It took 726 calls to achieve a sample of 514 family physicians. Characteristics of these physicians are shown in Table 1; the forms of their AHC responses are shown in Table 2. Message content ranged from no instructions for AHC to detailed advice. About 54% (277/514) of physicians’ messages provided a single instruction. The remainder gave combinations of choices. In total, the 514 after-hours messages generated 815 separate instructions that could be classified into 7 categories (Table 3). Three physicians forwarded their office calls to their homes. No physicians provided AHC instructions using Web-based or e-mail technology. "Go to emergency" was the sole instruction provided by 22% (111/514) of doctors. Another 18% (94/514) provided no AHC directions at all.


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  		Table 1 Characteristics of physicians in the study sample

 

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  		Table 2 Form of after-hours responses: N = 514.

 

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  		Table 3 Types of after-hours instructions provided by family physicians in the study sample

 
Logistic regression analysis (Table 4) revealed that physicians who were female, had hospital privileges, had CFPC Certification, or had graduated from a Canadian university were more likely to offer direct contact after hours. The association between physician availability and female sex could not be explained by more women practising in academic centres (where physicians are required to be available to support residents). No variables correlated significantly with the instruction "go to emergency." Variables that were not significant in the univariate analysis and were, therefore, not included in any of the regression models included "years since graduation" and "location" (city of Toronto versus the greater metropolitan area).


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  		Table 4 Results of multivariate logistic regression analysis indicating factors that were significantly (P <.05) associated with various after-hours care instructions

 

   DISCUSSION
TOP
 METHODS
 RESULTS
 DISCUSSION
Footnotes
 Acknowledgments
 References
 
The 7 distinct content categories of AHC instructions demonstrate that a description of care is possible. The variety of options likely reflects physician preferences and the fact that the greater Toronto area is home to the largest concentration of physician20 and patient populations in Canada.

Our study showed that most patients were left to determine the acuity of their illness on their own. Almost a quarter of the messages in our sample used "go to the emergency department" as their only AHC instruction. Overcrowding and visits to emergency rooms by nonurgent cases are long-standing problems in Toronto21 that highlight the need for physician education and systemic support to encourage physicians to offer alternatives for AHC.

About 18% of physicians provided no specific AHC directions to patients. When this figure is combined with the "go to emergency only" group, 40% of the physicians surveyed could be described as providing no useful AHC instructions for patients without critical illnesses. This lack of direction can lead to confusion, overextension of limited resources, and delays in seeking treatment. One initiative that attempts to address deficiencies is the provincial government’s 24-hour help line, Telehealth. This service was the least popular source of referral for physicians. Possible explanations include a lack of awareness of the service, a mistrust of government initiatives, discomfort with nurse-run telephone advice services (which use clinical algorithms), or resentment because Telehealth staff were salaried while at the time physicians were unpaid for giving telephone advice in Ontario. Further research will be needed to understand why physicians do not recommend Telehealth.

In our study, the percentage of Toronto physicians directly available after hours was lower than in the 1997 study by Patel et al14 (24% vs 54%). This might be explained by the fact that subjects in the study by Patel et al were all CFPC members, many of whom would have had Certification, a characteristic associated with being more directly available after hours in our study. It might also reflect real changes in service provision since 1997.

For offices where direct communication with a physician was available, physician characteristics (female sex, CFPC Certification, hospital affiliation, graduation from a Canadian medical school) had more influence on AHC instructions than practice characteristics (size, extended hours of operation, location). "Time since graduation," a substitute for age, which was not available to us, was not associated with this outcome. These findings might be explained by the fact that, in Canada, physicians have autonomy in their choice of after-hours arrangements. They also suggest that medical training has an influence on provision of AHC, an area that can be enhanced by curriculum initiatives. The lack of characteristics independently associated with the "go to emergency" instruction is likely a result of the many ways emergency referral is used (eg, "Go to emergency if you are having chest pain" or "The office is closed. Go to emergency") and the perceived medicolegal need to include a referral to emergency in any AHC message.

Limitations
This study has several limitations. First, because AHC provision has been found to vary by location,14,15 our findings might not be generalizable to rural or remote areas. We believe, however, that our findings are relevant to other urban settings and that the concepts and methods developed for our study are generalizable to other such studies. Second, our study inferred family physicians’ AHC arrangements from the content of their office after-hours telephone messages. This has the advantage of being a direct sample of what is available to patients who call, but some physicians provide additional instructions to their patients that we could not know about, for example, in practice brochures. Finally, this study does not address the issue of where patients actually go after hours, irrespective of the instructions they receive from their family physicians.

Conclusion
Strategies to improve AHC in Canada include appropriate remuneration for telephone advice and development of AHC service models that reflect the diversity of physicians and the communities they serve. Organizing physicians into group practices, strongly encouraged by government, will begin to address lifestyle issues affecting physicians and their decisions on providing AHC. A public awareness campaign is also needed to highlight proper use of emergency departments and identify local alternatives. This should take place along with attempts to reduce "unhelpful" AHC guidance from family physicians themselves. Examining the variability in AHC provision across the country would be useful in determining which jurisdictions have been most successful in addressing gaps in AHC and why.

Our study provides a template for examining AHC care and the factors (personal and systemic) that affect it. In the typology created, 4 physician characteristics were found to be associated with being directly available to patients after hours. It is of great concern that so many family physicians in our sample gave no useful guidance to patients who did not have serious illnesses. An initiative in primary care reform should build on the existing system, integrate changes, and continue to provide a range of AHC options for patients and physicians. Educating physicians to increase awareness of AHC options and systemic support from health authorities will contribute to effective and efficient changes in provision of AHC.



   EDITOR’S KEY POINTS
 
  • After-hours care (AHC) is a key facet of primary care, yet there has been little research into the AHC instructions family physicians give their patients.
  • Around 40% of family physicians surveyed in the greater Toronto area provided no useful AHC instructions for those not critically ill. Almost 25% only advised patients to go to an emergency department.
  • Strategies to improve AHC include proper remuneration for telephone advice, a public awareness campaign on appropriate use of emergency departments, and development of AHC models that meet the needs of both physicians and patients.

 


   Acknowledgments
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
 Acknowledgments
References
 
We thank Mary Young for her assistance with the project. We also thank the members of the North Toronto Primary Care Research Network (Nortren) for their support. The study was funded by an operating grant from the Physicians’ Services Incorporated Foundation.


   Footnotes
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
Acknowledgments
 References
 
This article has been peer reviewed.

Contributors

Dr Bordman, Ms Bovett, Dr Drummond, Dr Crighton, Dr Wheler, Dr Moineddin, and Dr White contributed to concept and design of the study, analysis and interpretation of data, and preparation of the article for submission.

Competing interests

None declared


   References
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
 Acknowledgments
 References
 

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