Methodological considerations
coronavirus disease 2019
REGRESSION, DISEASE, CORONAVIRUS DISEASE 2019, SECONDARY
The data from the Norwegian Directory of Health are reliable and a good source of information about the study population as well as activity in primary health care [The large proportion of the population being covered by the included out-of-hours GP cooperatives, in addition to narrow confidence intervals, indicate that the present study has statistical power to answer our research question.The e-learning course encouraged the nurses to not overrule the triage system in use in their own out-of-hours GP cooperative. Because many triage systems are less specific with regard to RTIs, generally with high sensitivity and low specificity for serious disease, this may have been an obstacle for change [The pragmatic intention-to-treat design yielded limited control on the implementation of the intervention. We do not know how many nurses completed the two educational parts, and how many nurses had access to the course without attending it. This makes the assessment of the effect of the intervention more uncertain. To compensate for this weakness, we included the number of nurses who had started on or completed the e-learning course per 1000 inhabitants as a variable in the regression model. This variable did not have a significant effect (IRR 0.98, 95% CI 0.80–1.19). The sensitivity analysis of this variable was not possible to perform, since the nurses in the control group were not exposed and the proportion of nurses in this group is zero.A longer intervention period might have increased the likelihood of a higher participation rate among nurses, but it would also increase the risk of external bias from the coronavirus disease 2019 pandemic. Hence, it is difficult to conclude about a lacking effect of the intervention based only on the primary and secondary outcomes. A pragmatic design is closer to real life and healthcare. We therefore considered it a pertinent method.