Non-compliance with a nurse's advice to visit the primary care provider: an exploratory secondary analysis of the TRIAGE-trial

Ines Homburg, Stefan Morreel, Veronique Verhoeven, Koenraad G Monsieurs, Jasmine Meysman, Hilde Philips, Diana De Graeve, Ines Homburg, Stefan Morreel, Veronique Verhoeven, Koenraad G Monsieurs, Jasmine Meysman, Hilde Philips, Diana De Graeve

Abstract

Background: During the cluster randomised TRIAGE-trial, a nurse advised 13% of low-risk patients presenting at an emergency department in Belgium to visit the adjacent general practitioner cooperative. Patients had the right to refuse this advice. This exploratory study examines the characteristics of refusers by uncovering the determinants of non-compliance and its impact on costs, as charged on the patient's invoice.

Methods: Bivariate analyses with logistic regressions and T-tests were used to test the differences in patient characteristics, patient status, timing characteristics, and costs between refusers and non-refusers. A chi-square automatic interaction detection analysis was used to find the predictors of non-compliance.

Results: 23.50% of the patients refused the advice to visit the general practitioner cooperative. This proportion was mainly influenced by the nurse on duty (non-compliance rates per nurse ranging from 2.9% to 52.8%) and the patients' socio-economic status (receiving increased reimbursement versus not OR 1.37, 95%CI: 0.96 to 1.95). Additionally, non-compliance was associated (at the 0.10 significance level) with being male, not living nearby and certain reasons for encounter. Fewer patients refused when the nurse perceived crowding level as quiet relative to normal, and more patients refused during the evening. The mean cost was significantly higher for patients who refused, which was a result of more extensive examination and higher out-of-pocket expenses at the ED.

Conclusions: The nurse providing the advice to visit the general practitioner cooperative has a central role in the likelihood of patients' refusal. Interventions to reduce non-compliance should aim at improving nurse-patient communication. Special attention may be required when managing patients with a lower socio-economic status. The overall mean cost was higher for refusers, illustrating the importance of compliance.

Trial registration: The trial was registered on registration number NCT03793972 on 04/01/2019.

Keywords: After-hours care; Costs; Emergency department; General practitioners cooperative; Non-compliance; Primary care; Triage.

Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: all authors received a grant from The Research Foundation –Flanders (FWO) for this project, covering the personnel and working costs; payment was made to their institutions. Author SM is a general practitioner working in the surroundings of the study site, and as such, he performed on call shifts at the study site and treated some of the studied patients. Due to the anonymity of the studied data, the exact number of study patients seen by him cannot be determined, but it was definitely below ten. He is also a board member of the studied general practice cooperative receiving meeting fees. Author HP is coordinator of the iCAREdata project (database used for this study). She had an appointment at the University of Antwerp for this project until September 2020. The authors declare no other relationships or activities that could appear to have influenced the submitted work.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
CHAID-analysis for refusing vs. accepting advice to visit the GPC. GPC: General practitioner cooperative
Fig. 2
Fig. 2
Rate of assignment to the GPC and patients’ rate of compliance, per nurse. GPC: General practitioner cooperative

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