From Doctor to Nurse Triage in the Danish Out-of-Hours Primary Care Service: Simulated Effects on Costs

Introduction. General practitioners (GP) answer calls to the Danish out-of-hours primary care service (OOH) in Denmark, and this is a subject of discussions about quality and cost-effectiveness. The aim of this study was to estimate changes in fee costs if nurses substituted the GPs. Methods. We applied experiences from The Netherlands on nurse performance in the OOH triage concerning the number of calls per hour. Using the 2011 number of calls in one region, we examined three hypothetical scenarios with nurse triage and calculated the differences in fee costs. Results. A new organisation with 97 employed nurses would be needed. Fewer telephone consultations may result in an increase of face-to-face contacts, resulting in an increase of 23.6% in costs fees. Under optimal circumstances (e.g., a lower demand for OOH services, a high telephone termination rate, and unchanged GP fees) the costs could be reduced by 26.2% though excluding administrative costs of a new organisation. Conclusion. Substituting GPs with nurses in OOH primary care may increase the cost in fees compared to a model with only GPs. Further research is needed involving more influencing factors, such as costs due to nurse training and running the organisation. 1. Introduction Many of the European out-of-hours (OOH) services are to some degree primary care based [1, 2], as the populations’ need for medical advice is often best met using a family medicine approach, except in emergency cases. In Denmark, a reform of the OOH primary care services in 1992 resulted in a considerable substitution of home visits by general practitioner (GP) telephone consultations and local GP clinic consultations [3, 4]. The OOH primary care is GP driven, based on a public scheme where GPs share the responsibility of providing care each weekday from 4？p.m. to 8？ a.m. and in weekends and on bank holidays [4]. Remuneration is based fully on a fee-for-service that varies by type of contact, receiving the highest fee for home visits and a higher fee for ending contacts on the phone as compared with referral to a subsequent face-to-face contact. Following the Danish reform in 1992, OOH primary care in, for example, The Netherlands and the United Kingdom was reformed into large-scale GP cooperatives inspired by the Danish solution [5, 6]. Danish GPs perform all clinical tasks themselves, whereas, in The Netherlands, nurses and nurse assistants answer patient calls and perform telephone triage. Supervised by a GP, the nurses/nurse assistants decide whether the patients are to be given a telephone advice or are to be