GPs and emergency primary health care

Consultation: the definition is taken from the Norwegian Medical Association’s ( Den Norske Legeforening ) ´´Normal tariff for private general practice 2016-2017´´ (link http://normaltariffen.legeforeningen.no/pdf/Normaltariff_2016.pdf - in Norwegian only), and the following rates are included:

• 2ad – Consultation with a doctor, day rate
• 2ak – Consultation with a doctor, evening rate
• 2ed – Group treatment per patient for guidance, instruction in own treatment and building a self-help network within a group of patients with chronic illnesses or disabilities
• 2ae - Electronic consultation. New in 2013

2ae - Electronic consultation is a new rate, and can only be used when there is already established a disease/disorder by the patients doctor. The communication must include a medical evaluation and is completed when the doctor has considered the request and given a response. Electronic consultation is only allowed on patient computer systems that can communicate on security level 4, due to the rules of information-security in health care and social services sector.

These rates are all  consultation rates for regular GPs. Other rates, like individual patient contact (including individual enquiries and advice given in person, via letter or telephone, writing of prescriptions and doctor’s certificates without consultation), tests carried out without a consultation and home visits, are all excluded from the statistics. Consultations and other contact with emergency clinics and specialists are included in the KUHR database, but are not included in the GP statistics.

Emergency primary health care tables are based on the following rates:

• 2ad – Consultation with a doctor, day rate
• 2ak – Consultation with a doctor, evening rate
• 2fk – Consultation and emergency response to medical practice during out-of-hours services  (new in 2012)
• 2nk – Emergency response from own home to medical practice for doctors on call at night (new in 2012)

Emergency primary health care services  : Municipalities in Norway are responsible for organizing emergency primary health care services for all inhabitants and visitors in the municipality (due to Municipal Health Services Act from 1984). GPs are obliged to give immediate medical help and to participate in the local emergency primary health care service. But approximately half of all municipal emergency work is done by other doctors, like full time emergency doctors, temps and hospital doctors. Lately we can see a change from municipal-based units to larger inter-municipal co-operations with regular employees and improved competence. Private emergency clinics are not included in the statistics.

Diagnoses : During a consultation the GP or the the doctor at the emergency care sets a diagnosis on the patient. These diagnoses are divided into either groups or chapters. The table showing the diagnosis groups are based on an aggregation of the ICPC-2 codes, into code-groups who in general practice belongs together, either because of similar etiology, approach or treatment. These groups represent some of the most common reasons why a patient seeks a doctor. The ICPC-2 codes in the different groups are given below:

• Infections of the respiratory passages, incl. ear infections: R05, R09-R23, R71-R83, H71-H74
• Local pains and infections: L01, L08-L17, L83, L87,L92,L93 
• Back problems: L02-L03, L84-L86
• General pains and muscle problems: A01, L18-L19, L29 
• Joint and rheumatic problems: L07, L20, L88-L91, L94
• Mental illness or mental health problems: P01-P26, P28, P29, P70-P99 
• Atopy, asthma, allergy or eczema: F71, R02-R03, R07, R96-R97, A92, S02, S87-S88, S98
• High blood pressure:  K85-K87 
• Heart diseases: K74-K84   
• Diabetes: T89, T90 
• Cancer: A79, B72-B74, D74-D77, F74, H75, K72, L71, N74, R84-R85, S77, T71,
• T73, U75-U77, W72, X75-X77, Y77-Y78
• Gynecological problems: X01-X22, X28, X29, X70-X74, X78-X81, X84-X99
• Functional intestinal problems: D1-D12, D17-D21, D84-D87, D90, D92, D93
• Skin infections: S03, S09-S11, S70-S76, S84-S85, S92-S93, S95
• Accidents and injuries: A80-A82, A86, A88, B77, D79-D80, F75-F79, H76-H79, L72-L81, L96, N79-N81, R87-R88, S12-S19, S80, U80, X82, Y80 
• Congenital illness or defects: A90, B78-B79, D81, F81, H80, K73, L82, N85, R89, S83, T78, T80, U85, X83, Y82-Y84
• Pregnancy, birth, contraception: W01-W99
• Fear of illness: A25-A27, B25-B27, D26-D27, F27, H27, K24-K27, L26-L27, N26-N27, P27, R26-R27, S26-S27, T26-T27, U26-U27, X23-X27, Y24-Y27
• Administrative contacts: A97
• Preventive contacts: A98, A981
• Other diagnoses: all other diagnoses

It is also possible to sort the diagnoses by chapters in the ICPC-2 manual (developed by Wonka International Classification Committee). In this system the doctor can code both the causes of contact, different health problems and diagnoses. The chapters are divided after where the symptoms or diseases are located in the body , such as eyes , ear , skin , etc. Cancer, for example,  will be spread over several chapters. The ICPC-2 manual contains 17 chapters from A to Z and is based on: general conditions (chapter A), organ systems (totally 14 chapters), psychological problems (chapter P) and social issues (chapter Z). The tables based on diagnoses contain only the main diagnosis set by the GP/emergency care unit, secondary diagnoses are not included.

Regular GP: the regular GP scheme was introduced on 1 June 2011, and gives everyone the right to be included on a list with a regular general practitioner. As of 31 December 2011, only 0.4 per cent of the population were not included in the scheme. Inclusion in the scheme has been stable since its inception in 2001 ( http://helsedirektoratet.no/finansiering/refusjonsordninger/tall-og-analyser/fastlege/Sider/fastlegestatistikken-2011.aspx - in Norwegian only). Patients may use a different regular GP where the selected GP has the capacity for this. The scheme is based on the local authorities entering into agreements with a sufficient number of independent regular GPs in order to provide the population with a professionally responsible offer, or employing doctors where relevant. Everyone with an address registered in the population register in Norway is entitled to a regular GP, as are refugees and NATO personnel with a D-number and their families. The doctors receive payment from the local authority for each patient on the list (per capita subsidy). The doctors also receive payment from patients and reimbursements from HELFO according to standard rates as described in the normal tariff. The maximum number of patients per doctor is 2 500. Further details are available at http://helfo.no (in Norwegian only).

Age is calculated as completed years at the end of the year. The following age groups are used: 0-5 years, 6-15 years, 16-19 years, 20-29 years, 30-49 years, 50-66 years, 67-79 years, 80-89 years and 90 years and older. In StatBank table 10 312 and 10 313 (Immigrant’s use of emergency primary health care, consultations, by age and country of origin), the two oldest age groups are merged into one since there are so few immigrants aged over 90 in some countries.

Gender : http://www.ssb.no/a/metadata/codelist/datadok/1531029/no

County of residence : http://stabas.ssb.no/ItemsFrames.asp?ID=4522005&Language=en&VersionLevel=ClassLevel

Immigrant category : http://stabas.ssb.no/ItemsFrames.asp?ID=5536158&Language=en&VersionLevel=ClassVersion

The following groupings are used in the statistics: Immigrants (code B), Norwegian-born to immigrant parents (code C), Other population (codes A, E, F, G).

Country background : http://www.ssb.no/a/metadata/conceptvariable/vardok/1919/en 

In the statistics, persons with immigrant category B (immigrants) are broken down into country background. For persons born outside Norway, the country background denotes (with very few exceptions) the person’s country of birth.

In the statistics, country background is broken down into five country groups:

• Nordic countries excluding Norway
• EU/EEA area excluding Nordic countries
• Europe outside EU/EEA
• Asia, Africa, Latin America, Oceania excluding Australia and New Zealand
• USA, Canada, Australia and New Zealand

Statistics are also published for 10 individual countries (Denmark, Sweden, Poland, Vietnam, Iran, Germany, Somalia, Philippines, Iraq and Pakistan).

Level of education : http://stabas.ssb.no/ItemsFrames.asp?ID=4846001&Language=en&VersionLevel=ClassVersion 

The following groupings are used in the statistics: primary and lower secondary level, upper secondary level, university and university college level, in addition to ´´No education/unspecified´´. Persons under the age of 16 are not included in level of education tables.

Name: GPs and emergency primary health care
Topic: Health

Division for Health, care and social statistics

National level and county. But diagnoses and emergency health care are only published on a national level.

Annual publication.

We use doctor consultations from the KUHR database (control and payment of reimbursements to health service providers), combined with other data sources, in the variable: «Doctor consultations (in all settings) – average number of consultations/visits with a physician per person per year». The variable is reported in «Joint Questionnaire» who reports data to OECD, Eurostat and WHO-Europe.

Microdata, information on the sample and population are stored as text files.

The statistics on regular GPs’ and emergency primary health care consultations aim to provide an overview of the population’s use of GP and emergency primary health care services. The statistics are replacing the sporadic surveys and statistics publications that have not provided an adequate picture of use of these services.

Data from the KUHR database (for the control and payment of reimbursements to health service providers) and links to the variables of patients taken from Statistics Norway’s statistical registers are used to form a picture of the population’s use of regular GPs and emergency primary health care. The statistics show how often residents consult a GP or emergency primary health care, whether men or women use the service to the same extent, whether different age groups differ in their use of the service, whether there are disparities between various immigrant categories, whether immigrants with different countries of origin use the service to the same extent and how use of a regular GP or emergency wards varies according to the patient’s level of education.

Tables of diagnoses set by a GP was new in 2013, and tables of diagnosis set by an emergency doctor came in 2015. One of the most important tasks for a medical doctor is to set a diagnosis based on symptoms and / or signs on the patient. There are thousands of different diseases; some occur frequently others are rarer. By sorting the diagnoses set during a consultation in to groups or chapters based on ICPC-2 code practice, we can learn more about the most common reasons that a patient seeks their doctor. The diagnoses tables are sorted by sex and age. Since knowledge about diagnoses is regarded as sensitive health information, SSB has received these in an anonymous version. Therefore we are not able to add extra socioeconomic variables.

The public, health authorities, other public bodies, interest groups, professional bodies and researchers. Data from the doctors’ payment database combined with Statistics Norway’s statistical registers will provide new information on the use of doctors, and show variations between different groups in the population.

No external users have access to the statistics and analyses before they are published and accessible simultaneously for all users on ssb.no at 10 am. Prior to this, a minimum of three months' advance notice is given inthe Statistics Release Calendar. This is one of Statistics Norway’s key principles for ensuring that all users are treated equally.

The Norwegian Directorate of Health: http://www.helsedirektoratet.no/publikasjoner/data-fra-allmennlegetjenesten/Sider/default.aspx (in Norwegian only)

The Norwegian Health Economics Administration (HELFO) analysed 2009 data in a report on regular GPs, emergency clinics and registered specialists ( Analyserapport. Fastleger, legevakt og avtalespesialister. Aktivitetsstatistikk 2009 ). This report builds on an update of the analysis conducted by the Norwegian Labour and Welfare Service (NAV) in 2007 of KUHR data on 2006 consultation statistics ( Hva foregår på legekontorene? Konsultasjonsstatistikk for 2006 ), see NAV report 4/2007 (in Norwegian only). The analyses by HELFO and NAV include the patients’ gender and age, while Statistics Norway’s statistics include several variables relating to patients, level of education, immigrant category and country of origin.

A number of tables relating to regular GPs are published every year as part of the health care personnel publications ( http://www.ssb.no/english/subjects/06/01/hesospers_en/ ). The statistics include variables on the regular GPs (gender, age, county of practice, immigrant category and country of birth), variables on the municipality of practice (centrality, size of municipality) and variables of patient lists (open vs. closed patient list). Data on regular GPs are also included in a range of indicators that are published in KOSTRA factsheets within the municipal health service subject area, see http://www.ssb.no/kostra/stt/index.cgi?nivaa=2&;regionstype=kommune .

In 2005, Statistics Norway carried out a project on the population’s use of general practitioner services; the SEDA project, which was based on patient data from a sample of doctors, see report 2007/15 (in Norwegian only).

Statistics are published on activity in hospitals using the Norwegian Patient Register (NPR) as a data source. Statistics Norway publishes the statistics annually at http://www.ssb.no/english/subjects/03/02/pasient_en/ . As with the KUHR database, the statistics are based on a register in which individuals can be identified.

National Centre for Emergency Primary Health Care in Bergen conducts research and promotes knowledge about emergency primary health care. For more information, articles or tables, see: http://helse.uni.no/default.aspx?site=8

In 2008, Statistics Norway published a report on the health of immigrants 2005/2006. The report presents the results of the health-related questions in Statistics Norway’s survey Living conditions among immigrants 2005/2006. The survey takes a representative sample of immigrants and descendants aged 16-70 who have lived in Norway for two years or more who have a background from Bosnia-Herzegovina, Serbia-Montenegro, Turkey, Iraq, Iran, Pakistan, Vietnam, Sri Lanka, Somalia and Chile. The report compares the immigrant population’s health with the health of the population as a whole based on the ordinary living conditions surveys in 2002 and 2005. See report 2008/35 (in Norwegian only). Different methodology and data sources for the statistics on the population’s use of GPs and questions on the use of such services in the sample survey mean that results are not directly comparable.

Statistics Act, § 3.2 (Administrative registers)

No

The statistics cover all persons who are residents of Norway. Persons living in Norway temporarily are not included in the statistics.

The data source for patient data is the KUHR database, which is an administrative register for the control and payment of reimbursements to health service providers. The Norwegian Directorate of Health is the owner of the database and it is administered by the Norwegian Health Economics Administration (HELFO). The KUHR database contains all types of patient contacts for which a fee is payable.

Data from the KUHR database is supplemented with demographic variables for the patients, which are taken from the Central Population Register (CPR) held by the Directorate of Taxes. Every day, Statistics Norway receives electronic reports from the CPR of all changes in the population. The reports are used to update a separate population database used for statistical purposes in Statistics Norway, and this forms the basis for the statistics on the composition of the population. For further details, see Statistics Norway’s Focus on Population .

The data on patients’ level of education are retrieved from Statistics Norway’s National Education Database (NUDB). NUDB contains information on all education a person has completed. For more information on NUDB, see About the statistics relating to the statistics on level of education in the population and http://www.ssb.no/vis/magasinet/slik_lever_vi/art-2006-09-14-01.html (in Norwegian only).

Total count. All persons who are residents of Norway are covered by the statistics.

The KUHR database is based on electronically submitted reimbursement claims from doctors to HELFO. Reimbursement claims sent in paper format are not included, but these make up a very small and declining share of claims. Doctors are reimbursed for patient treatment pursuant to § 5-4 of the National Insurance Act ( Folketrygdloven ). Most regular GPs submit their reimbursement claims electronically. The reimbursement claims also provide an overview of patients’ own share of costs and thereby form the basis for the allocation of health care exemption cards. In an agreement with the Norwegian Directorate of Health (register owner), Statistics Norway receives data from HELFO (register administrator) every year.

Data are subjected to controls and an internal revision by HELFO with a view to reimbursements to doctors and follow-up of patients’ own costs. Statistics Norway undertakes a further control of the data material through links to the population database and Statistics Norway’s education register, NUDB. Registered consultations that are lacking unique identifiers for patients are discarded, i.e. invoices with incomplete or incorrect personal ID numbers. Consultations for patients that do have a unique identifier but who are not Norwegian residents (according to Statistics Norway’s population database) are also discarded. This includes persons with a financial connection to Norway who can be identified with a unique D-number [1] . Non-residents also include persons who have emigrated from Norway. Around two per cent of all registered consultations are discarded (2010 figures).

The tables are based on diagnosis codes from the International Classification of Primary Care (ICPC-2).  Only valid codes are included in the statistics, but small errors may still occur.

Average rates are calculated for different groups in the population.

[1] A D - number is a temporary number that is issued, for example, to foreign nationals who are liable for tax or VAT in Norway.

Not relevant

Figures cannot be published where an individual’s identity could be revealed. The statistics follow Statistics Norway’s general rules on confidentiality, and figures are not published if three or fewer observations are given in a cell.

The statistics on GPs were published for the first time in 2012 for the year 2010. While consultations at emergency primary health care wards were published for the first time in January 2014 for the year 2012. Annual updates will be given on ssb.no.

Only persons resident in Norway and registered with a valid personal identification number are included in the statistics. Where a patient does not remember his/her personal identification number at the time of consultation, or gives an incorrect personal identification number, the consultation is not included in the statistics. Previously, the patient had to keep a record of payments made to the health service, but since 2010, patients’ own costs and issues of health care exemption cards have been registered electronically. There is reason to believe that this change has helped reduce errors and omissions in the registration of personal identification numbers. In 2010, one per cent of personal identification numbers given for GP  consultations registered in KUHR lacked one digit. The level of personal identification numbers missing for emergency primary health care consultations in 2012 were much higher, 11 per cent. However, we still have information on age and sex for this group, but not information about education and immigration background. In 2013 it's only 3 per cent of the emergency care consultations that lack a valid identification number.

The diagnoses: of 13, 5 million main diagnoses (in 2013) set by GPs during consultation, it is assumed that about. 40 000 of these have a wrong diagnosis code. This is approx. 0.3 percent of the data.

Not relevant