Robert Anders Burman

• Burman, Robert Anders; Zakariassen, Erik & Hunskaar, Steinar (2014). Management of chest pain: A prospective study from Norwegian out-of-hours primary care. BMC Family Practice. 15(1:51). doi: 10.1186/1471-2296-15-51. Full text in Research Archive Show summary

  Background: Chest pain is a common diagnostic challenge in primary care and diagnostic measures are often aimed at confirming or ruling out acute ischaemic heart disease. The aim of this study was to investigate management of patients with chest pain out-of-hours, including the use of ECG and laboratory tests, assessment of severity of illness, and the physicians’ decisions on treatment and admittance to hospital. Methods: Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with “chest pain” were analysed. Results: A total of 832 patients with chest pain were registered. The first 100 patients (corresponding doctor-patient pairs) were included in the study according to the predefined inclusion criteria. Median age of included patients was 46 years, men constituted 58%. An ECG was taken in 92 of the patients. Of the 24 patients categorised to acute level of response, 15 had a NACA-score indicating a potentially or definitely life-threatening medical situation. 50 of the patients were admitted to a hospital for further management, of which 43 were thought to have ischaemic heart disease. Musculoskeletal pain was the second most common cause of pain (n = 22). Otherwise the patients were thought to have a variety of conditions, most of them managed at a primary care level. Conclusions: Patients with chest pain presenting at out-of-hours services in Norway are investigated for acute heart disease, but less than half are admitted to hospital for probable acute coronary syndrome, and only a minority is given emergency treatment for acute coronary syndrome. A wide variety of other diagnoses are suggested by the doctors for patients presenting with chest pain. Deciding the appropriate level of response for such patients is a difficult task, and both over- and under-triage probably occur in out-of-hours primary care.

• Burman, Robert Anders; Zakariassen, Erik & Hunskaar, Steinar (2014). Chest pain out-of-hours - An interview study of primary care physicians' diagnostic approach, tolerance of risk and attitudes to hospital admission. BMC Family Practice. 15:207. doi: 10.1186/s12875-014-0207-4. Full text in Research Archive Show summary

  Background: Acute chest pain constitutes a considerable diagnostic challenge outside hospitals. This will often lead to uncertainty in choosing the right management, and the physicians’ approach may be influenced by their knowledge of diagnostic measures and their tolerance of risk. The aim of this study was to investigate primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission in patients with acute chest pain out-of-hours in Norwegian primary care. Methods: Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with “chest pain” were analysed. Tolerance of risk was measured by the Pearson Risk Scale and the Tolerance of Risk Scale, the latter developed for this study. Results: “Patient history and symptoms” was considered the most important, and “negative ECG” and “effect of sublingual nitroglycerine” the least important aspects in the diagnostic approach. There were no significant differences in length of experience or gender when testing “risk avoiders” against the rest. Almost all physicians felt that their risk assessment out-of-hours was reasonably good, and felt reasonably safe, but only 50% agreed with the statement “I don’t worry about my decisions after I’ve made them”. Concerning chest pain patients only, 51% of the physicians were worried about complaints being made about them, 75% agreed that admitting someone to hospital put patients in danger of being “over-tested”, and 51% were more likely to admit the patient if the patient herself wanted to be admitted. Conclusions: Physicians working out-of-hours showed considerable differences in their diagnostic approach, and not all physicians diagnose patients with chest pain according to current guidelines and evidence. Continuous medical education must focus on the diagnostic approach in patients with chest pain in primary care and empowerment of physicians through training and emphasis on risk assessment and “tolerance of risk”.

• Burman, Robert Anders; Zakariassen, Erik & Hunskaar, Steinar (2011). Acute chest pain - a prospective population based study of contacts to Norwegian emergency medical communication centres. BMC Emergency Medicine. 11(9). doi: 10.1186/1471-227X-11-9. Full text in Research Archive Show summary

  Background: Acute chest pain is a frequently occurring symptom in patients with medical emergencies and imposes potentially life threatening situations outside hospitals. Little is known about the epidemiology of patients with acute chest pain in a primary care setting in Norway, and we aimed to obtain more representative data on such patients using data from emergency medical communication centres (EMCCs). Methods: Data were collected prospectively during three months in 2007 from three EMCCs, covering 816 000 inhabitants. The EMCCs gathered information on every situation that was triaged as a red response (defined as an “acute” response, with the highest priority), according to the Norwegian Index of Medical Emergencies. Records from ambulances and primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes and The National Committee on Aeronautics (NACA) System scores were assigned retrospectively. Only chest pain patients were included in the study. Results: 5 180 patients were involved in red response situations, of which 21% had chest pain. Estimated rate was 5.4 chest pain cases per 1000 inhabitants per year. NACA-scores indicated that 26% of the patients were in a lifethreatening medical situation. Median prehospital response time was 13 minutes; an ambulance reached the patient in less than 10 minutes in 30% of the cases. Seventy-six per cent of the patients with chest pain were admitted to a hospital for further investigation, 14% received final treatment at a casualty clinic, while 10% had no further investigation by a doctor (“left at the scene”). Conclusions: The majority of patients with acute chest pain were admitted to a hospital for further investigation, but only a quarter of the patients were assessed prehospitally to have a severe illness. This sheds light on the challenges for the EMCCs in deciding the appropriate level of response in patients with acute chest pain. Overtriage is to some extent both expected and desirable to intercept all patients in need of immediate help, but it is also well known that overtriage is resource demanding. Further research is needed to elucidate the challenges in the diagnosis and management of chest pain outside hospitals.

• Melberg, Tor; Burman, Robert Anders & Dickstein, Kenneth (2010). The impact of the 2007 ESC-ACC-AHA-WHF Universal definition on the incidence and classification of acute myocardial infarction: A retrospective cohort study. International Journal of Cardiology. ISSN 0167-5273. 139(3), p. 228–233. doi: 10.1016/j.ijcard.2008.10.021. Full text in Research Archive Show summary

  OBJECTIVE: To investigate the impact on the apparent incidence and classification of acute myocardial infarction (AMI) after employing the ESC-ACC-AHA-WHF 2007 Universal definition of myocardial infarction (the 2007 definition). SETTING: Retrospective cohort study in a single hospital serving a geographically well-defined population. METHODS AND RESULTS: Retrospectively, the medical records for all patients hospitalized with suspected AMI during 2004 were reviewed (915 with AMI discharge diagnosis, 1037 with elevated troponin T>0.03 µg/L without AMI diagnosis, 948 undergoing revascularisation and 34 with sudden death possible due to AMI). After correcting for misclassification (49 overdiagnosed and 236 underdiagnosed AMI) the number of AMI according to the 2000 definition was 1102 (20.5% overall underdiagnosed). After reclassification to the 2007 definition the total number of AMI cases decreased with 9 patients mainly due to increase of the troponin decision limit for PCI related AMI (reducing the number of PCI related AMI from 111 to 69). The percentages of patients of each type according to the 2007 subclassification were spontaneous AMI (type 1) 88.5%; AMI due to myocardial oxygen deficit (type 2) 1.6%; sudden death without troponin elevation (type 3) 2.6%; PCI related AMI (type 4) 6.8%; and AMI after coronary artery bypass (type 5) 0.5%. CONCLUSIONS: Employing the 2007 revision of the Universal definition of AMI did not substantially alter the apparent incidence of acute AMI substantially in our population. The level of misclassification of acute coronary syndromes after introduction of the 2007 definition may depend on the clinical acceptance of AMI subgrouping.

• Zakariassen, Erik; Burman, Robert Anders & Hunskår, Steinar (2010). The epidemiology of medical emergency contacts outside hospitals in Norway a prospective population based study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18, p. 9–9. doi: 10.1186/1757-7241-18-9. Full text in Research Archive Show summary

  Introduction: There is a lack of epidemiological knowledge on medical emergencies outside hospitals in Norway. The aim of the present study was to obtain representative data on the epidemiology of medical emergencies classified as "red responses" in Norway. Method: Three emergency medical dispatch centres (EMCCs) were chosen as catchment areas, covering 816 000 inhabitants. During a three month period in 2007 the EMCCs gathered information on every situation that was triaged as a red response, according to The Norwegian Index of Medical Emergencies (Index). Records from ground ambulances, air ambulances, and the primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes (ICPC-2) and The National Committee on Aeronautics (NACA) Score System were given retrospectively. Results: Total incidence of red response situations was 5 105 during the three month period. 394 patients were involved in 138 accidents, and 181 situations were without patients, resulting in a total of 5 180 patients. The patients' age ranged from 0 to 107 years, with a median age of 57, and 55% were male. 90% of the red responses were medical problems with a large variation of symptoms, the remainder being accidents. 70% of the patients were in a non-life-threatening situation. Within the accident group, males accounted for 61%, and 35% were aged between 10 and 29 years, with a median age of 37 years. Few of the 39 chapters in the Index were used, A10 "Chest pain" was the most common one (22% of all situations). ICPC-2 symptom codes showed that cardiovascular, syncope/coma, respiratory and neurological problems were most common. 50% of all patients in a sever situation (NACA score 4-7) were > 70 years of age. Conclusions: The results show that emergency medicine based on 816 000 Norwegians mainly consists of medical problems, where the majority of the patients have a non-life-threatening situation. More focus on the emergency system outside hospitals, including triage and dispatch, and how to best deal with "everyday" emergency problems is needed to secure knowledge based decisions for the future organization of the emergency system.

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• Meland, Eivind & Burman, Robert Anders (2013). Brystsmerter. In Hunskaar, Steinar (Eds.), Allmennmedisin. Gyldendal Akademisk. ISSN 9788205401921. p. 156–160. Full text in Research Archive
• Wesnes, Stian Langeland; Kristoffersen, Espen Saxhaug & Burman, Robert Anders (2012). Fastlegeordningen trenger flere leger. p. 674–676. doi: 10.4045/tidsskr.12.0119. Full text in Research Archive
• Thesen, Janecke; Burman, Robert Anders & Selnes, LD (2012). Grunnleggende tiltak for en bedre fastlegeordning. Full text in Research Archive
• Burman, Robert Anders (2011). Samhandling mellom psykiatrien og fastlegene - frem og tilbake like langt? Utposten. ISSN 0800-5680. 6, p. 28–30. Full text in Research Archive
• Burman, Robert Anders (2010). Akutte brystsmerter utenfor sykehus - kun hjertesmerte? Scandinavian Update Magazine. ISSN 1890-9493. 3(3), p. 30–33. Full text in Research Archive
• Burman, Robert Anders; Zakariassen, Erik & Hunskaar, Steinar (2010). Acute chest pain - A prospective population based study of contacts to Norwegian emergency medical communication centres. Full text in Research Archive
• Burman, Robert Anders & Hunskaar, Steinar (2015). Chest pain out-of-hours. Prospective studies on diagnostics and management in out-of-hours emergency primary health care in Norway. Universitetet i Bergen. ISSN 9788230826218. Full text in Research Archive

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