Patient safety and predictors for subsequent healthcare contact after self-care referral from Swedish ambulance services: a retrospective cohort study

Ambulance clinicians increasingly refer patients to self-care, positioning ambulance service within a wider gatekeeping role and necessitating the assessment of whether self-care is a safe option or if further support is needed. Contrary to primary healthcare centre (PHC) referrals, self-care referrals often lack structured follow-ups, with the decision consequences remaining underexplored. This study investigates the outcomes and predictors of subsequent healthcare contact (SHC) and mortality among patients referred to self-care by ambulance services in three Swedish regions. This retrospective cohort study included 6,452 (954 children and 5,498 adults) ambulance assignments between 1 January 2023 and 31 December 31 2023 that resulted in self-care referrals. The primary outcome was SHC (PHC visits, ambulance service recontact, emergency department visits, and hospitalisations) and all-cause mortality within 72 h and 30 days. Bayesian multilevel logistic regression models were used to estimate the probability of recontact and mortality. Approximately 30% and 25% of the adults and children sought SHC, respectively, with the majority being PHC visits. Mortality was < 2% within 30 days, and no deaths were observed among the children. Respiratory, infectious, and medical symptoms predominated among the children, compared with medical, surgical, and neurological symptoms among adults. Predictors of SHC included increased age, longer on-scene time, advisory decision support system (ADSS) use, and distance to hospital. Approximately one-third (30%) of patients sought SHC within 72 h of a self-care referral decision. Whilst this does not necessarily indicate adverse events, the lack follow-up and patient-reported data limits interpretation. Although the ADSS have the potential to reduce ED conveyance, they cannot replace nuanced clinical judgment, risking inequitable care for patients in rural areas, those with low health literacy, and frail older adults. Non‑conveyance decisions for patients aged 80 years or older should therefore be approached with heightened caution. Future research should explore patient perspectives to better understand re-engagement and improve the safety of self-care referrals.