Abstract
Introduction
In recent years, the increasing availability of instruments and laboratory tests has significantly influenced the diagnostic work in primary healthcare. This study aimed to map the availability of diagnostic equipment and point-of-care tests (POCTs) in Norwegian emergency primary healthcare clinics and examine the demographic and organisational factors influencing their availability.
Methods
This cross-sectional study utilised the National Out-of-Hours Services Registry (NOOHR) survey across all Norwegian emergency primary healthcare clinics in early 2024. Clinic managers provided data on diagnostic equipment and POCTs. Clinics were categorised by population size, hospital proximity, co-location with general practitioner (GP) offices, and total equipment available.
Results
All 167 Norwegian emergency primary healthcare clinics responded. The median number of diagnostic equipment and POCTs was 17 (Interquartile range (IQR) 16–20). Clinics with the most equipment were often smaller, co-located with a GP office, and over 40 km from a hospital. Almost all clinics had a repertoire of CRP, urinary dipstick, haemoglobin, glucose, strep A test, SARS-CoV-2 rapid test, urinary HCG test, pulse oximeter, and ECG. Clinics far from hospitals more frequently had tests like D-dimer and troponin. Of the clinics with troponin tests, 69% had a low-sensitive POCT.
Conclusion
Norwegian emergency primary healthcare clinics are well equipped, especially if co-located with a GP office or far from a hospital. Further research is needed to enlighten how availability influences use and the possible impact on patient trajectories. Clinic leaders should pave the way for sustainable practices and high-value care when deciding their diagnostic equipment and POCTs repertoire.
Keywords: Point-of-care tests, diagnostic equipment, low-value care, gatekeeping, emergency primary healthcare, healthcare organization, healthcare sustainability, out-of-hours services
Introduction
Primary healthcare is the entry point to acute healthcare in many European countries, being accessible and addressing healthcare needs in hours and out-of-hours [1]. Primary healthcare is characterised by limited access to diagnostic equipment and depends on secondary healthcare for more advanced investigations. However, in line with the general technological development, various diagnostic instruments and laboratory tests have been developed and become available in primary healthcare. Point-of-care tests (POCTs) provide rapid results aiming to confirm or rule out diagnoses and are increasingly available [2–4].
The European trend of upscaling emergency primary healthcare clinics to bigger units may facilitate the implementation of more diagnostic equipment [5]. Norway has followed the trend, and many municipalities have moved from clinics staffed with a GP on duty in a GP office to larger clinics with auxiliary personnel and several physicians [6–8].
Significant variations exist in the availability and use of POCTs and other diagnostic equipment in European emergency primary healthcare [9]. The Scandinavian countries stand out with high usage compared to other countries [10–14]. Organisational factors such as funding, centralisation, distance to the nearest hospital, and co-location with a GP office or an emergency department may affect the availability and use of diagnostic equipment and laboratory tests [10,15,16].
Norwegian general practitioners (GPs) are obliged to work duties in emergency primary healthcare and manage 58% of all consultations [17,18]. Full-time emergency primary healthcare physicians, interns and locums cover the remaining. When a perceived medical need arises outside of regular hours, the inhabitants must contact emergency primary healthcare for assessment, treatment and gatekeeping for secondary healthcare. Although life-threatening conditions are of low frequency, the primary purpose of the emergency primary care assessment is to clarify the degree of severity and the need for further investigations or treatment [19–22]. Hence, emergency primary healthcare physicians play an important role in sorting patients who can wait, need treatment or need an acute referral to a hospital [23–25].
The Norwegian state finances emergency primary healthcare, including most POCTs and several diagnostic equipment through reimbursement claims per used test or examination performed [26]. The reimbursement is paid to the physician or the municipality, depending on local salary agreements. Haemoglobin, glucose, urine dipsticks, strep A and CRP tests are established as obligate POCTs in Norwegian emergency primary care clinics [15,27]. The CRP POCT has been the most used test in Norwegian emergency primary healthcare clinics over the last decade, and its use has increased for respiratory tract infections and other clinical indications [10,28]. Differentiating between self-limiting infections and those needing antibiotic treatment is essential, and the CRP POCT is most often used for this purpose.
Available POCTs and diagnostic equipment combined with incentives for use may contribute to low-value care, a problem with rising attention worldwide [29]. The Norwegian Choosing Wisely campaign for primary healthcare addresses the overuse of the CRP POCT and rapid tests for streptococci and advises against ordering blood tests with no clinical indication or consequence [30].
Little is known about the frequency or factors determining the availability of non-obligated POCTs and diagnostic equipment. White blood cell count (WBC) and rapid tests for RS-virus and influenza are examples of non-obligated POCTs used for infection assessments. However, their diagnostic accuracy is yet to be established, the evidence seems dubious, and the extent of their usage is unknown [31]. Low-sensitive POCT troponin is another test with dubious clinical benefits [32]. It is used to clarify whether a patient with chest pain has acute coronary syndrome, but its availability in Norwegian emergency primary healthcare is unknown.
This study aimed to map available diagnostic equipment and POCTs in all Norwegian emergency primary healthcare clinics and identify demographic and organisational factors affecting their availability.
Material and methods
Design
This cross-sectional study was based on a survey among all Norwegian emergency primary healthcare clinics.
Setting and data collection
The survey was part of the biennial data collection for the National Out-of-Hours Services Registry (NOOHR). NOOHR is a national registry containing information on the organisation, resources, equipment, and local procedures of all emergency primary healthcare services in Norway. The National Centre for Emergency Primary Health Care updates the registry through online surveys. The survey is sent to clinic managers who have comprehensive knowledge about the clinic. Non-responders receive two e-mail reminders and subsequent contact by telephone until a complete dataset has been obtained. The 2024 survey was launched in early January 2024 and included specific questions regarding diagnostic equipment and POCTs (supplementary file). Before any analyses, the author group judged some of the questions less relevant for this study and were therefore not included as variables.
Data on centrality (a municipality’s geographical position relative to a centre with higher order or functions) and population size served by each emergency primary healthcare clinic were collected from Statistics Norway [33]. The distance to the nearest hospital was collected from Google Maps based on addresses available and maintained in NOOHR [34].
In November 2024, the NOOHR survey was supplemented with a short online survey about the troponin test among the 63 clinics that reported having this test available. One of the authors (MA) contacted non-responders by telephone.
The emergency primary care clinics were a priori divided into five categories based on population size served: ≤5,000, 5,001–10,000, 10,001- 50,0000, 50,001–100,000, and >100,000. Grounded on clinical experience and a pragmatic assumption of how driving distance affects patient transportation and the ability to use the laboratory of the nearest hospital, the clinics were a priori divided into three groups based on the distance to the nearest hospital (<1 km/no travel time, 1–40 km/five to 30 min drive, >40 km/> 30 min drive). Dichotomies were made between co-located with a GP office (yes/no) and covering one or more municipalities.
A variable for the total number of the different diagnostic equipment (pulse oximeter, ECG, ultrasound, spirometer, tonometer, pulsed doppler, bladder scanner, microscope, and tympanometer) and POCTs (CRP, urinary dipstick, haemoglobin, s-glucose, strep A, Sars-CoV-2, urinary HCG, troponin, HbA1c, d-dimer, WBC, INR, mononucleosis, RSV, pro-BNP, s-ALAT, influenza, s-creatinine, s-natrium, blood gas) was created for each clinic. This variable was divided into quartiles, and the clinics in each quartile (low, medium-low, medium-well, and well-equipped) were compared.
Analyses
Frequencies and percentages were used to describe data distribution about diagnostic equipment and POCTs. The Chi-Square test was used to compare shares. StataSE 18 (StataCorp. 2023. Stata Statistical Software: Release 18. College Station, TX: StataCorp LLC) was used for the statistical analyses.
Results
A complete data set was obtained with answers from all 167 emergency primary care clinics serving Norway’s 5,550,203 inhabitants in 2023 (Table 1). Half of the clinics covered two or more municipalities. There was considerable variation between clinics regarding population size, centrality, distance to a hospital, and whether the clinic was co-located with a GP office. The Chi-Square test showed an association between a long distance to a hospital and the clinic co-located with a GP office (p < 0.001).
Table 1.
Norwegian emergency primary healthcare clinics – organisational factors.
| Emergency primary care clinics | Population served | |
|---|---|---|
| N (%) | N (%) | |
| Total | 167 (100) | 5,550,203 (100) |
| Groups of clinics by population served | ||
| 0–5,000 | 48 (29) | 106,284 (2) |
| 5,001–10,000 | 25 (15) | 190,686 (3) |
| 10,001–50,000 | 64 (38) | 1,540,970 (28) |
| 50,001–100,000 | 19 (11) | 1,365,102 (25) |
| > 100,000 | 11 (7) | 2,347,161 (42) |
| Centrality (1–6) | ||
| 5 and 6 (least central) | 85 (51) | 624,175 (11) |
| 3 and 4 | 63 (38) | 2,248,634 (41) |
| 1 and 2 (most central) | 19 (11) | 2,677,394 (48) |
| Distance from hospital (0–367 km) | ||
| < 1 km | 30 (18) | 1,686,886 (30) |
| 1–40 km | 51 (31) | 3,032,943 (55) |
| >40 km | 86 (52) | 830,374 (15) |
| Municipalities covered (1–12) | ||
| One municipality | 83 (50) | 1,875,223 (34) |
| Two or more municipalities | 84 (50) | 3,674,980 (66) |
| Co-located with GP office | ||
| No | 96 (58) | 4,877,154 (88) |
| Yes | 71 (43) | 673,049 (12) |
Number of tests
The total number of different diagnostic equipment and POCTs per out-of-hours clinic ranged from 10 to 30, with a median of 17 (IQR 16–20) (Table 2).
Table 2.
Total number of diagnostic equipment and POCTs in norwegian emergency primary care clinics by organisational factors.
| Quartiles (Q) of the total number of diagnostic equipment and POCTs |
||||||
|---|---|---|---|---|---|---|
| 10–15 (Q1) | 16–17 (Q2) | 18–20 (Q3) | 21–30 (Q4) | |||
| N (%) | N (%) | N (%) | N (%) | Total N (%) | Χ² test | |
| Number of clinics | 59 (35) | 27 (16) | 43 (26) | 38 (23) | 167 (100) | |
| Distance to hospital | ||||||
| 0 km | 15 (50) | 6 (20) | 3 (10) | 6 (20) | 30 (100) | |
| 1–40 km | 22 (43) | 10 (20) | 13 (26) | 6 (12) | 51 (100) | |
| >40 km | 22 (26) | 11 (13) | 27 (31) | 26 (30) | 86 (100) | 0.019 |
| Municipalities covered | ||||||
| Single | 24 (29) | 13 (16) | 24 (29) | 22 (27) | 83 (100) | |
| Multiple | 35 (42) | 14 (17) | 19 (23) | 16 (19) | 84 (100) | 0.307 |
| Co-location GP office | ||||||
| No | 46 (48) | 16 (17) | 19 (20) | 15 (16) | 96 (100) | |
| Yes | 13 (18) | 11 (16) | 24 (34) | 23 (32) | 71 (100) | <0.001 |
| Population served | 1,777,547 (32) | 1,651,814 (30) | 1,310,729 (24) | 810,113 (15) | 5,550,203 (100) | |
The 38 clinics in the quartile with the most diagnostic equipment and POCTs served the smallest population (15%), were more likely to be co-located with a GP office and situated more than 40 km from a hospital.
The diagnostic equipment and POCTs repertoire fell into three levels (Figures 1 and 2). The basic-level repertoire of the CRP, haemoglobin, s-glucose, strep A, and Sars-CoV-2 POCTs, urinary dipstick and HCG-test, and pulse oximeter and ECG was available in almost all the clinics. The medium-level repertoire was found in 38–72% of the clinics and included the troponin, HbA1c, d-dimer, WBC, INR and mononucleosis POCTs, as well as the diagnostic equipment ultrasound, spirometer, tonometer, pulsed doppler and bladder scanner, in addition to the basic repertoire. The high-level repertoire of the RSV, influenza, pro-BNP, s-ALAT, s-creatinine, s-natrium and blood gas POCTs, and microscope and tympanometer in addition to the two other repertoire levels, was found in 7–24% of the clinics.
Figure 1.
POCTs Available in norwegian emergency primary healthcare clinics.
Figure 2.
Imaging and function tests available in norwegian emergency primary care clinics.
The clinics were more likely equipped with the POCTs D-dimer, HbA1c, WBC, INR, and troponin if the distance to a hospital was more than 40 km (Figure 3). On the other hand, clinics located less than one km from the nearest hospital were more likely to have a bladder scanner (Figure 4).
Figure 3.
POCTs Available in norwegian emergency primary healthcare clinics, per distance to hospital.
*=P ≤ 0.05, **=P ≤ 0.01, ***= P ≤ 0.001.
Figure 4.
Diagnostic equipment in norwegian emergency primary healthcare clinics, per distance to hospital.
*=P ≤ 0.05, **=P ≤ 0.01, ***= P ≤ 0.001
A total of 43 (69%) emergency primary healthcare clinics who reported having troponin test used a low-sensitive POCT, while 5 (8%) used a high-sensitive. The remaining 14 clinics (23%) sent their troponin tests for analysis in a hospital laboratory. One clinic had ceased using troponin tests.
Of the clinics using a low-sensitive troponin POCT, 37 (86%) used Cobas h 232 POC (Roche), and six were unsure or did not answer this question.
Discussion
Main findings
More than 95% of Norwegian emergency primary care clinics had a basic repertoire of diagnostic equipment and POCTs, consisting of ECG, pulse oximeter, urinary dipstick and HCG test, and CRP, haemoglobin, blood glucose, strep A, and Sars-Cov-2 POCTs. Highly equipped clinics were more likely co-located with a GP office and situated more than 40 km from a hospital.
Comparison with existing literature
Despite European emergency primary healthcare clinics having similar diagnostic scope, there are considerable differences in the availability and use of POCTs [9]. The Nordic countries and the Netherlands have high usage, while others rely on clinical assessments. The CRP (99%) and Strep A (92%) POCTs were highly available in Norwegian emergency primary care clinics in 2009, and their availability has now reached 100% and 98%, respectively [15]. The basic repertoire described in our study is available in more than 95% of the clinics, a slight increase from around 90% in the former study. The pulse oximeter is new to this category, which could be explained by professional development, including a focus on vital parameters and triage systems in assessing patients.
Diagnostic equipment and POCTs in the medium-level repertoire saw the highest increase compared to 2009, with WBC and D-dimer POCTs rising by 50 percentage points [15]. In contrast, the availability of tonometer, spirometer and microscope fell by 20, 8 and 50 percentage points, respectively. The changes in availability may partly be due to the reduction of emergency primary healthcare clinics between the two studies [15]. 2009, there were 209 clinics, but by 2024, this number had decreased to 167. One might argue that less-equipped clinics were merged with better-equipped ones. However, the number of emergency primary healthcare clinics co-located with a GP office had decreased from 2009 to 2024 [35]. Hence, factors other than merging clinics probably explain the increase in the medium-level repertoire.
The fee-for-service in Norwegian primary healthcare incentivises physicians to use the POCTs CRP, s-glucose, strep A, Sars-CoV-2, Urinary HCG test, Mononucleosis, INR, WBC, HbA1c and the diagnostic equipment ECG, bladder scanner, pulsed Doppler, tonometer, spirometer, ultrasound, and microscope. The other POCTs and equipment do not generate reimbursement. Except for ultrasound and bladder scanners, this financial system has been unchanged for more than 20 years, except for minor adjustments after yearly negotiations between the state and the Norwegian Medical Association. This consistency has probably contributed to our finding of an increased availability of medium-level equipment [15].
Norway has a dispersed population. The municipalities have, therefore, invested in accessible primary healthcare services, including emergency primary healthcare. For clinics with long distances to a hospital, the need for diagnostic equipment and POCTs could be perceived as higher than in clinics located within or close to a hospital for two reasons. The first is that long transportation of patients may be avoided with a good repertoire of diagnostic equipment and tests. The second is that clinics closer to a hospital may use the hospital laboratory for diagnostic blood tests. The association with distance to a hospital on the choice of diagnostic equipment and POCTs seems to outweigh the anticipated impact of upscaling emergency primary care clinics to larger units [5]. Our finding of higher troponin POCT availability in clinics more than 40 km from a hospital illustrates this distance association. Another possible explanation for the distribution of highly equipped clinics in rural areas could be the high rate of co-location with the GP offices in these areas. Due to their broader diagnostic scope and task, Norwegian GP offices are usually better equipped than emergency primary healthcare clinics. The finding of an association between distance to a hospital and co-location with a GP office indicates that both factors contribute to this finding.
Clinical value of POCTs for infection and chest pain assessments
Diagnostic equipment and POCTs should aid the clinical diagnostic process and sometimes form decisions. Therefore, leaders of emergency primary healthcare clinics should choose diagnostic tests based on their potential clinical impact [36]. We found that Norwegian emergency primary healthcare clinics have tests that may be characterised as of high clinical value, such as s-glucose and tests for infection assessment. We also found examples of low-clinical impact tests, like RSV and low-sensitive troponin POCTs. We will discuss infection tests and troponin in more detail.
Assessing infections is common in emergency primary healthcare clinics across Europe [37–40]. A recent review of reviews concludes that current evidence is insufficient to support the routine use of POCTs for respiratory tract infections in primary and emergency healthcare. In contrast, a Cochrane review concludes that using CRP will likely reduce antibiotic prescriptions [31,41]. Our finding of 100% availability confirms that Norwegian emergency primary healthcare clinics have embraced the CRP POCT. Despite its questionable clinical impact, CRP belongs to the standard repertoire and is likely to influence patient trajectories for infectious diseases [42–44]. WBC POCT is less studied in primary care, and its role in infection assessment, except possibly for pneumonia, remains unclear [44,45]. Strep A POCT, conversely, seems to reduce the antibiotic prescribing rate for sore throat [46]. The Norwegian guidelines recommend that it be used in decisive ways with the Centor criteria [47].
Troponin could have a substantial clinical impact in emergency primary healthcare clinics, definitively influencing chest pain patients’ trajectories. Chest pain is the second most frequent diagnosis in acute referrals from primary healthcare, whereas only 26% are discharged with a coronary disease diagnosis [48]. However, the analytical precision for the decision threshold (the 99th percentile upper reference limit) of various cardiac troponin assays is crucial for clinical decision-making. This standard is not met for low-sensitivity tests, like the most common troponin test in Norwegian emergency primary healthcare clinics [32]. The clinical consequence is that acute coronary syndrome may not be ruled out, even with a negative result. Their availability in rural clinics may be explained by a desire to avoid unnecessary long transportation of chest pain patients. However, this desire seems to have overruled current knowledge about the tests’ very low clinical impact, and their availability and use are highly questionable. A high-sensitive troponin POCT may rule out acute coronary syndrome outside hospitals and could be particularly beneficial for remote clinics [49]. However, these tests have not been validated for all emergency primary healthcare settings [50].
Perspectives
POCTs contribute to greenhouse gases in production, transportation, use, and waste management, and the cartridges may contain toxic compounds like cyanide derivatives [51]. These aspects need increased awareness in the medical community in general and in primary healthcare in particular. Our finding of the high availability of POCTs and other diagnostic equipment in Norwegian emergency primary healthcare clinics does not equal high usage in the same clinics, and one could argue that an available test is not problematic from a sustainable perspective. However, the Norwegian reimbursement system facilitates using the available tests, even when the potential clinical impact is low. Moreover, all tests have date limitations and will generate emissions whether or not they are used.
High use of POCTs yields a medical challenge of many false positives, resulting in over-treatment, inappropriate patient trajectories, and weakened patient safety [52,53]. In addition, it increases the public’s expectations of performed tests, leading to increased use. Telephone triage nurses reporting requests for CRP tests rather than medical assessments from emergency primary healthcare clinics call for rethinking the use of the CRP POCT in Norway [54].
When determining which POCTs and diagnostic equipment should be available in emergency primary healthcare settings, it is essential to balance the three key considerations: their clinical impact, the clinic’s local conditions, like the distance to a hospital or co-location with other healthcare facilities, and their environmental impact. These three considerations may resemble a tightrope walk for clinic leaders, and the consequence is that it may be difficult to make standard repertoires, both within a country and across borders. However, we agree with Luigi et al. that sustainable practices can reduce low clinical impact testing, improve the healthcare economy, and improve patient safety [53].
Strengths and limitations
This study is a repetitive survey addressed to the leaders of emergency primary healthcare clinics. There are no missing clinics in the data, ensuring there is no selection bias. Further, the National Centre for Emergency Primary Health Care has a trustful relationship with the leaders, facilitating well-founded responses. This enables a complete picture of how Norwegian emergency primary healthcare clinics are equipped for diagnostic purposes.
The survey method itself is a limitation. There is always a risk that respondents misunderstand questions or answer what they believe is correct rather than what is the reality. This risk is probably higher when leaders answer the survey than when healthcare personnel do. However, most of the leaders of out-of-hours clinics are nurses or physicians, leading their clinics hands-on. The survey investigates equipment availability, but we have no information on how each clinic’s repertoire was chosen or how clinicians use the available equipment. However, availability is a prerequisite for using POCTs and other diagnostic equipment.
The survey gives only a snapshot of the clinics’ available equipment at the time of the survey. For instance, the Sars-Cov-2 test was an important POCT during the COVID-19 pandemic to define outbreaks and give suitable infection control advice. COVID-19 is now treated like other viral respiratory tract infections, and the need for the Sars-Cov-2 rapid test is limited. There is reason to believe that the number of clinics having this test is dropping.
Conclusion
We found that Norwegian emergency primary healthcare clinics are well equipped, and almost all had the CRP, haemoglobin, s-glucose, strep A and Sars-CoV-2 POCTs, urinary dipstick and HCG-test, pulse oximeter and ECG. Being co-located with a GP office or situated a long distance from a hospital correlated with having more diagnostic equipment and different POCTs available. We believe there may be a higher perceived need for equipment to support diagnostic processes when no hospital laboratory is nearby and when patients who need hospital referral must travel long distances.
Future studies should investigate how availability influences use and the possible impact on patient trajectories. Furthermore, local decision-making processes regarding the choice of equipment repertoire need attention.
A high number of POCTs and diagnostic equipment in emergency primary health care clinics may lead to improved diagnostics, but it may even lead to overuse, with potential adverse effects. We believe this is a call to all levels of emergency primary health care leaders to ensure continuous education of physicians and auxiliary personnel to increase awareness of the risks, help them choose wisely, and avoid low-value care for the best of patients and the environment.
Supplementary Material
Disclosure statement
No potential conflict of interest was reported by the author(s).
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