Summary
Epistaxis was responsible for 302,782 cases corresponding to 160,963 persons insured with the AOK Lower Saxony. The cases seen by GP and ENT specialists were comparable with regard to age and sex distribution. Hypertension, atrial fibrillation/flutter and an antithrombotic therapy were slightly more common among cases consulting a GP. The GP recorded more co-diagnoses than the ENT.
The use of outpatient care and its distribution among the groups of physicians fluctuated scarcely between 2007 and 2016. Twenty-three thousand one hundred eighteen patients (14.4%) had been diagnosed by both ENT and GP during a relatively short time period.
The practice fee remuneration had no impact on the consultation of the physician groups.
Consideration regarding patient allocation
The present study shows that epistaxis is a common symptom and has a high and rising impact on the German health care system. In contrast, population-based data on the epidemiology of epistaxis is scarce. Most studies in literature were either limited to a hospital setting or to specific populations like infants [13,14,15,16,17]. Next to differences in health care systems, this hampers comparisons in an international context. In a recent study using the same data basis, the prevalence of epistaxis treated in the in- and outpatient setting increased from 8.6 (2007) to 9.3 (2016) per 1000 insured persons (+ 21%) [12].
The patient groups seen by GPs and ENT specialists did not substantially differ in their age structure and comorbidities. This indicates that specialist i.e. ENT medical treatment is not only limited to severe epistaxis. This observation is confirmed by the analysis of the invoiced fee positions. Thus, a missing allocation of patients, i.e. a lack of gatekeeping, can be documented during the entire observation period of 10 years. The allocation of a patient to a GP, ENT or emergency department based on the severity of disease is not always reasonable. A recent cross-sectional study in an out-of-hours primary care center in northwestern Germany showed a remarkable high proportion of younger patients with non-urgent complaints [18]. In addition to differences in the access to these facilities, the assessment of urgency and the role of the primary care physician also differs between the countries.
The practice fee did not prevent the patient population of this study from visiting a specialist, thus the practice fee was not a useful instrument for cost-effective patient allocation in our study population. Whether patients’ own co-payments sensibly control the use of medical services is controversially discussed [19, 20]. We assume that a deductible has a controlling effect if medical services are demanded more often than actually necessary. In case of epistaxis the patient can rarely estimate the actual amount and seriousness of blood loss and the controllability by the patient’s own co-payment is limited. Furthermore, it is likely that 10 euros do not constitute a significant burden for many people. In addition, the waiting times for an appointment with an ENT specialist in Germany are comparatively short [3, 21].
The influence of the SHI Care Strengthening Act, also known as the Appointment Service Act, could not be conclusively examined in this study due to its introduction at the end of the study period (16.07.2015). The proportion of ENT consultations remained relatively stable during 2016 (see Fig. 1).
Consideration regarding patient care
With regard to the care epistaxis patients received in the present study, it is striking that from the age of 20 years onwards a similar number of patients were treated by GP and by ENT specialists. Why is the GP involved in only about 36% of the cases, when 90–95% of all anterior epistaxis cases are proven to be easily treatable [10, 22] and a specific epistaxis therapy was only billed by the ENT specialist in every fifth patient? We assume that most patients directly consulted the ENT specialist without visiting the GP first or at all.
The German Society for General and Family Medicine (DEGAM) defines the responsibility of the GP as the first medical contact and basic care provider for all patients with physical and mental health disorders in emergency, acute and long-term care as well as areas of prevention and rehabilitation [23].
The present study cannot provide a conclusive assessment of the quality of GP care. However, the small number of patients (14.4%) who visited an ENT specialist and a GP in the same or two consecutive quarters suggests that primary care was successful in most cases and/or a referral to an ENT specialist was only necessary in every seventh patient. In addition to being easier to reach and thus providing faster emergency care, GPs are usually more familiar with the patient. Hypertensive urgencies, for example, were far more often documented by GPs than by ENT specialists. This is interesting in the sense that high blood pressure can be the cause of epistaxis. Further, low blood pressure can be a sign of high blood loss. Whether these measurements were performed as an assessment of the patient’s condition in an emergency situation or as a search for possible causes of epistaxis cannot be derived from the data. The average (median) number of recorded co-diagnoses, which suggest causal components, was also substantially higher among GPs than among ENT specialists.
Only malignant tumors were mainly recorded by the ENT physician due to the diagnostic value of the endoscopy. However, these were rather rare diagnoses.
Regardless of the severity of epistaxis, the ENT specialists consider their medical therapy as optimum care [10, 24]. The reasons for this are the incorrect assessment of blood loss and thus the severity of epistaxis by non-specialist physicians – in this case GP and pediatricians – and the frequent lack of basic emergency care [25, 26]. The latter statements are based on studies published 1993 and 2005, respectively. To our knowledge, there are no more recent studies.
Future impact and possible improvements
The outpatient treatment of epistaxis constitutes a considerable burden. Due to the demographic development with an increase of age-related diseases and the associated increase in multimorbidity, a further increase of epistaxis is to be expected [26, 27]. This is further aggravated by the reduction in the number of specialists, especially in rural areas [28]. Primary care provided by GPs is likely to be sufficient for most epistaxis cases. We recommend studies to examine and, if necessary, optimize the quality of primary care for epistaxis.
The practice fee did not lead to better patient allocation between primary and secondary care. Thus, GP-centred care might be necessary to reach the goal of directing patients to primary care first [29]. It better addresses an adequate allocation of resources, providing specialists more time to consult on serious cases.
By means of targeted performance management and controlled allocation of (expensive) diagnostics, a managed care model allows holistic care in the sense of “disease management” [30]. On the one hand, this will lead to an improvement in efficiency, quality and continuity of care, on the other hand to possible cost savings by avoiding unnecessary examinations [31].
Taking epistaxis as a model disease its low cost-effective treatment may be reflected in the treatment of other conditions. We recommend population-wide studies regarding possible cost savings in the treatment of common diseases in the primary care sector.
Strengths and limitations of the study
The major strengths of this study are the large database and the long time period of 10 years.
However, the present study is limited by the nature of the data of a single statutory health insurance. It is known that insurances differ with respect e.g. to demographics, socio-economic status and morbidity, which limits the generalizability of the results [32].
Furthermore, it was not possible to determine whether the patients first visited the GP and then, e.g. due to a referral, the ENT specialist, since the diagnoses could only be assigned to a quarter, but not to a specific date within this quarter. Possible budgetary reasons (e.g. total time budget at the end of the quarter), which could have influenced the billing of the ENT physician, could not be excluded either. Finally, the role of institutions such as ambulatory out-of-office-hours services which were probably included in the 8% of cases not linked to a physician specialty, could not be further evaluated.
Nevertheless, we considered the collected data to be relevant to analyze the outpatient care of epistaxis in Germany.
