Do out-of-hours general practitioner services and emergency departments cost more by collaborating or by working separately? A cost analysis

Strength in the gap: A rapid review of principles and practices for urgent care centres

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining "after-hours care," "ambulatory care," "emergency medicine," "urgent care," "minor emergency," "walk-in," and "Canada" over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

Minor traumatic injuries in the emergency department pre- and post-implementation of an emergency care access point

OBJECTIVE

In the Netherlands, out-of-hours General Practice Cooperatives (GPCs) increasingly collaborate with Emergency Departments (EDs) to form an Emergency Care Access Point (ECAP). ECAPs aim to decrease the number of low-urgent ED attendances, of which many compromise minor traumatic injuries. In this study, we evaluated the impact of ECAP implementation on the incidence of minor traumatic injuries in the ED.

METHODS

We evaluated a total of 2772 ED patients who presented with a minor traumatic injury (categorized into traumatic wounds and isolated extremity injuries) 1 year before and 1 year after ECAP implementation. We compared patient characteristics, throughput, diagnosis, treatment and follow-up before and after ECAP implementation.

RESULTS

ECAP implementation was associated with a reduction in ED volume for minor traumatic injuries: -12.4% for isolated extremity injuries (1249 vs. 1094) and -74.6% for traumatic wounds (342 vs. 87). Multivariable logistic regression analysis controlling for patient characteristics showed that ECAP implementation was associated with higher rates of substantial injuries in the ED (OR 1.20, 95% CI = 1.01-1.43), and more patients requiring outpatient follow-up.

CONCLUSION

Implementation of an ECAP was associated with a reduction of ED utilization by patients with minor traumatic injuries, traumatic wounds in particular. This healthcare intervention may therefore help to reduce ED utilization for low-urgent complaints.

Association between acute care collaborations and health care utilization as compared to stand-alone facilities in the Netherlands: a quasi-experimental study

Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.

Associations between structures, processes and outcomes in inter-municipal cooperation in out-of-hours services in Norway: A survey study

Inter-municipal cooperation (IMC) has gained widespread recognition as a beneficial strategy for improving efficiency and quality in the provision of out-of-hours emergency care services (OOH services). Little attention, however, has been given to the additional costs of cooperation and the relational processes through which benefits and costs are likely to result. Based on survey data from 266 (77%) Norwegian municipalities involved in IMC in OOH services in 2015, this study aimed to investigate how the structure (governance form, complexity and stability) and quality (trust and consensus) of cooperation processes interact to influence the perceived outcomes (benefits and costs) of IMC in OOH services. Using Structural equation modeling, we found trust and consensus fully mediated the association between the structure and outcomes of IMC. More specifically, the results suggest that cooperation structures characterized by centralized governance, stability over time, and reduced complexity were likely to enhance the benefits and reduce the costs of IMC through trust and consensus.

Do employees benefit from collaborations between out of hours general practitioners and emergency departments?

BACKGROUND

In an attempt to redirect patients who are inappropriately attending hospital emergency departments (ED) and in doing so provide the right care at the right place, out-of-hours GP (General Practitioner) services and EDs increasingly collaborate in Urgent Care Collaborations (UCCs). Work satisfaction is an important factor in analysing the impact of this organisational change. The objective of this study is, firstly, to discover if there is a difference in the employee experiences between those working in UCCs and those in traditional out-of-hours services in which EDs and out-of-hours GP services operate separately (i.e. "usual care"). Secondly, we would like to identify which factors affect employees' experiences in these settings.

METHODS

This study followed a cross-sectional study design, comparing usual care with UCCs. Data regarding employee experiences were collected from physicians, nurses, nurse practitioners, medical assistants and front desk personnel, by means of a questionnaire with scales regarding quality, workload and co-operation between the out-of-hours GP service and ED. Independent samples t-tests were used to determine mean differences between the settings. Multiple linear regression analyses were performed to test which items affected the perceived quality, workload and co-operation.

RESULTS

The results showed that mutual co-operation alone was perceived as significantly better in UCCs compared to usual care. If divided between employers, no differences were found in the employee experiences working in out-of-hours GP services. ED employees in UCCs experienced a significantly better co-operation with their GP colleagues than their peers in the usual care setting, but also a higher workload. Remarkably, ED employees were less satisfied in general. The multiple regression model showed that perceived quality, workload and co-operation were interrelated. Co-operation was the only aspect that was rated higher in the UCC setting.

CONCLUSION

While perceived quality is equal and co-operation between out-of-hours GP service and ED is better, the objective and perceived ED workload was higher in UCCs compared to usual care. Though UCCs relieve the pressure on EDs concerning the number of patients, they seem to aggravate the workload. EDs need to be careful not to excessively adjust staff capacity when responding to lower numbers of patients.