Key results
Compared with the EMS, adult callers to out-of-hours primary care were younger, more often female, were more often employed, more often had a high educational level and self-reported more often good health status. Several motives were associated with higher probability of contacting the EMS versus contacting out-of-hours primary care. Most of these motives related to own assessment and expectations, but some motives related to previous experience and knowledge or needs and wishes. Motives associated with lower probability were mostly related to perceived barriers and benefits. Only four motives associated with contacting the EMS versus out-of-hours primary care differed significantly between children and adults.
Comparison with existing literature
To our knowledge, no previous studies have compared patients calling out-of-hours primary care and the EMS within one design, but several studies have investigated patients calling out-of-hours primary care [
29‐
32]. In line with these single-service studies and clinical experiences, we found some differences between patients calling out-of-hours primary care and patients calling the EMS. As in other studies, women more often than men contacted out-of-hours primary care, and a considerable part of calls to out-of-hours primary care concerned children [
29‐
32]. Two Danish studies on EMS contacts reported similar percentages of calls made by women, but these studies found a slightly lower mean age than found in our study [
33,
34]. This difference is likely to be due to our stratification into groups (children and adults) and exclusion of patients aged 13–18 years.
The most important motives found in our study for contacting out-of-hours primary care were partly in line with other studies. Worry and need for reassurance are frequently mentioned motives in out-of-hours primary care, as also found in other studies [
12,
35,
36]. Kallestrup et al. reported that symptom relief was an important motive in about one third of contacts to out-of-hours primary care [
35]. Parents of Dutch children with fever have been found to contact to get reassurance from a professional [
37], and a considerable part of Dutch patients have reported a perceived need to see a GP [
12]. We found that perceived availability and accessibility of own GP play a role for a minority of patients, as found by Keizer et al. [
12].
As far as we know, only few previous studies have focused on motives for contacting the EMS [
3,
38]. The existing studies found motives similar to the motives identified in our study. Booker et al. also reported that worry and anxiety were two important motives [
3]. Furthermore, they found that callers with care responsibilities tend to contact the health care service that is expected to provide the promptest response, as decision making is driven by lower tolerance of perceived risk [
3]. This result is closely related to our finding that callers could not take responsibility. In line with our findings, Ahl et al. found that the need for immediate help was an important criterion for deciding to contact ambulance care [
38], and patients are aware that ambulance services provide a quick response [
3]. In addition, some of the identified motives seem to match those found for patients self-referring to the ED, such as easier access to diagnostic tests and symptoms perceived to be too severe to be handled by the GP [
14‐
17].
Patients frequently contacting out-of-hours primary care and the EMS [
1‐
4] do not always choose the most suitable health care service provider [
23,
31,
39‐
43], which could cause delay of care, overcrowding, overtreatment and overuse of resources. It is important to acknowledge the patient’s role in the complex decision-making process when facing an acute health care problem. The traditional focus on medical relevance should instead be directed towards ways of assisting the patient in the decision-making process (patient-centredness). Contacting a less suitable health care service may occur because of little knowledge of available acute health care services and/or of suitable care for specific symptoms. The identified motives for calling the EMS (i.e. expectation of prompt diagnostics or need for specialist care, hospital admission or ambulance dispatch) reflect the patients’ own assessment of symptoms and own care expectations, which seem in line with the more acute character of EMS. Patients make this conclusion on the basis of their knowledge of the health care system [
36] and of the disease presentation.
The availability and accessibility of own GP and personal barriers (‘no opportunity to call the GP’, ‘need for quick help because of work/daycare’) could be areas of improvement, as these motives were mentioned by patients at both health care services. Several other studies have shown an association between the accessibility of own GP and use of out-of-hours primary care [
36,
44]; this association may also be relevant for EMS contacts. In our study, most patients stated that their need emerged outside the opening hours of their own GP. The need to contact health care may truly have appeared outside the opening hours [
45], but the answers could also have been biased by social desirability. Parents may find it difficult to decide whether to contact out-of-hours primary care for a health problem occurring outside office hours or wait until the opening hours of own GP [
36], whereas GPs may find that patients have a low threshold for contacting out-of-hours care [
46].
Strengths and limitations
We conducted a large-scale study exploring patient characteristics and motives to contact the out-of-hours health care services in two Danish regions, with parallel data collection at out-of-hours primary care and the EMS. The developed questionnaire was found to have good face and content validity, and three small-scale pilot studies ensured further optimisation. Based on literature and feedback from experts and patients, we acquired a thorough overview of relevant patient motives for contacting out-of-hours care. Yet, our studies also had some limitations.
We cannot rule out selection bias, even though our response rate (44.9%) was acceptable for this type of study. The non-response analysis showed that some characteristics differed between our respondents and non-respondents. This may have influenced our results on important motives for contacting out-of-hours care, as some motives related to specific patient groups. A considerable drop-out rate was seen at out-of-hours primary care as some patients declined participation. We predefined 26 motives that were considered relevant for contacting out-of-hours care and asked the respondents to assess their importance. Thus, the patients could point out multiple relevant motives, without ranking the most important ones. This approach allowed us to consider the impact of all motives, including the ones perceived as less important, which is relevant for the understanding of the decision-making process in patients. Our list of 26 predefined motives may not be complete, thus introducing some bias. Yet, as our list was defined after an extensive procedure, we expect this bias to be minimal. Primarily, we studied the motives underlying decision-making, without assessing suitableness or patient outcome. However, we could not rule out social desirability bias, as patients may have wanted to give suitable and acceptable motives for their contact and the received health care. We included all contacts, including bystander calls to EMS. As questionnaires were answered by patients, some information bias may appear for bystander calls. Yet, most calls were made by family members or other known bystanders. Finally, generalisation of findings to other populations in similar health care systems should be made with caution, as the access to both out-of-hours primary care and the EMS is free of charge in Denmark and access is by telephone call.
Recommendations for future research and clinical practice
Our study contributes to understanding the complex decision-making process of patients in need of acute health care. This knowledge may contribute to suitable adjustment of the existing health care services, aiming to optimise patient safety and service level without increasing health care costs. Previous studies have found that patients do not always access the most suitable service, which could be caused by a range of factors. Future studies focusing on the identified motives seem relevant, such as the importance of the availability and accessibility of own GP for the decision to contact out-of-hours primary care and the potential effect of ensuring better availability and accessibility. Furthermore, an international comparison could be interesting, giving the opportunity to study different organizational and health care system factors in relation to motives for help seeking. Moreover, patients could be assisted by public information campaigns on available health care services and target groups, and the effects of creating one access point to acute care could be explored.