Patient pathways and short-term outcomes following nurse-led first-contact unscheduled visits in primary care: A multicentre cohort study.

BACKGROUND

Unscheduled primary care demand is placing increasing pressure on primary health care systems, prompting policies that position nurses on the front line. Nurse-led care protocol-guides are now widely used. However, patient pathways from the reason for unscheduled daytime visits to the end of the care process remain poorly understood.

OBJECTIVE

This study aimed to quantify the volume and clinical profile of unscheduled walk-in daytime visits in primary care, characterize the full nurse-led care pathway within a collaborative model, and evaluate the determinants of scheduled follow-up and unscheduled reconsultation within 8 days.

DESIGN

Multicentre retrospective cohort study using routinely collected electronic health record data from unscheduled daytime primary care visits.

SETTINGS: Three primary care centres with an assigned population of 107,515 citizens in Barcelona, Spain.

PARTICIPANTS

All eligible patients with an unscheduled daytime walk-in visit between April and July 2025 who were initially assessed by a nurse under a protocol-guided pathway.

METHODS

Data were extracted from the electronic health records system. The index visit was the first unscheduled consultation during the study period. Outcomes included unscheduled reconsultation and scheduled follow-up within 8 days. Causal mediation analysis assessed whether general practitioner referral mediated the association between reason for consultation and reconsultation. Competing-risks models with Fine-Gray subdistribution hazard models examined factors associated with each outcome, treating the alternative outcome as a competing risk.

RESULTS

Of 29,532 nurse visits, 2624 (8.9%) were unscheduled and met the eligibility criteria. Of these, 54.2% were managed by nurses without general practitioner referral. Referral at the index consultation was not associated with a reduced risk of unscheduled reconsultation (OR, 1.16; 95% CI, 0.88-1.52). Instead, reconsultations were more strongly associated with clinical factors, particularly mental health complaints (OR, 4.54; 95% CI, 2.19-9.43), fever (OR, 3.03; 95% CI, 1.40-6.57), and digestive symptoms (OR, 2.58; 95% CI, 1.41-4.74). In competing risk models, referral was associated with a lower subdistribution hazard of scheduled follow-up within 8 days (sHR 0.55, 95% CI 0.44-0.75), suggesting different follow-up patterns between nurse-managed and GP-referred pathways.

CONCLUSIONS

Most visits were not followed by short-term unscheduled reconsultation, and reconsultations appeared to reflect patients' clinical needs rather than nurse-to-GP referral decisions. These findings are consistent with the potential role of nurse-led care pathways in organizing same-day demand and supporting care planning by managing appropriate cases and, when needed, directing follow-up to scheduled primary care visits.