Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data

Identifying markers of health-seeking behaviour and healthcare access in UK electronic health records

OBJECTIVE

To assess the feasibility of identifying markers of health-seeking behaviour and healthcare access in UK electronic health records (EHR), for identifying populations at risk of poor health outcomes and adjusting for confounding in epidemiological studies.

DESIGN

Cross-sectional observational study using the Clinical Practice Research Datalink Aurum prelinked to Hospital Episode Statistics.

SETTING

Individual-level routine clinical data from 13 million patients across general practices (GPs) and secondary data in England.

PARTICIPANTS

Individuals aged ≥66 years on 1 September 2019.

MAIN OUTCOME MEASURES

We used the Theory of Planned Behaviour (TPB) model and the literature to iteratively develop criteria for markers selection. Based on this we selected 15 markers: those that represented uptake of public health interventions, markers of active healthcare access/use and markers of lack of access/underuse. We calculated the prevalence of each marker using relevant lookback periods prior to the index date (1 September 2019) and compared with national estimates. We assessed the correlation coefficients (phi) between markers with inferred hierarchical clustering.

RESULTS

We included 1 991 284 individuals (mean age: 75.9 and 54.0% women). The prevalence of markers ranged from <0.1% (low-value prescriptions) to 92.6% (GP visits), and most were in line with national estimates; for example, 73.3% for influenza vaccination in the 2018/2019 season, compared with 72.4% in national estimates. Screening markers, for example, abdominal aortic aneurysm screening were under-recorded even in age-eligible groups (54.3% in 65-69 years old vs 76.1% in national estimates in men). Overall, marker correlations were low (<0.5) and clustered into groups according to underlying determinants from the TPB model.

CONCLUSION

Overall, markers of health-seeking behaviour and healthcare access can be identified in UK EHRs. The generally low correlations between different markers of health-seeking behaviour and healthcare access suggest a range of variables are needed to capture different determinants of healthcare use.

Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation

Background

Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models.

Objectives

To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models.

Design

Mixed-methods realist evaluation.

Methods

Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development.

Results

General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models.

Limitations

The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored.

Conclusion

Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services.

Future work

The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy.

Study registration

This study is registered as PROSPERO CRD42017069741.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

Transforming Primary Care: Developing Health Precincts as Models for Sustainable Integrated Community-Based Healthcare

Holistic healthcare precincts are an emerging service model to address the growing health service demands of ageing consumers and an increasing prevalence of chronic diseases. In Australia and similar countries with universal publicly funded Medicare systems, the first point of access to healthcare is provided by general medical practitioners. This case report focuses on successful components of a private, integrated, patient-centred primary care model located in a low socioeconomic population in North Brisbane, Queensland. Successful components included a focus on sustainability, general practice as an anchor tenant in the health precinct, the integration of multiple services, team-based care for shared clinical services, flexible expansion options, the use of MedTech, support for small businesses and a cluster structure. The Morayfield Health Precinct (MHP) offers appropriate, safe and individualised healthcare to residents across their life continuum. Its success was built on a foundation of pre-planning, to ensure the design/build, anchor tenant and collaborative ecosystem were sustainable in the long term. MHP planning was based on an adaptation of the WHO-IPCC framework supporting true patient-centred, integrated care. Its shared vision and collaborative care are supported by its internal governance structure, tenant selection, established and emerging referral networks and partnerships. Evidence-based and informed care is further supported by internal and external research and education partnerships.

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.

Co-location of out of hours primary care and emergency department in Belgium: patients' and physicians' view

Background

In Belgium, General Practitioner Cooperatives (GPC) aim to improve working conditions for unplanned care and to reduce the number of low acuity emergency visits. Although this system is well organized, the number of low acuity visits does not decrease.

Methods

We explored the view of patients and physicians on the co-location of a GPC and an emergency service for unplanned care. The study was carried out in a cross section design in primary and emergency care services and included patients and physicians. Main outcome measure was the view of patients and physician on co-location of a GPC and an emergency service.

Results

404 patients and 488 physicians participated. 334 (82.7%) of all patients favoured a co-location. The major advantages were fast service (104, 25.7) and adequate referral (54, 13.4%). 237 (74%) of the GPs and 38 (95%) of the emergency physicians were in favour of a co-location. The major advantage was a more adequate referral of patients. 254 (79%) of the GPs and 23 (83%) of the emergency physicians believed that a co-location would lower the workload and waiting time and increase care quality (resp. 251 (78%), 224 (70%) and 37 (93%), 34 (85%).

Conclusions

To close the expectation gap between GP’s, emergency physicians and to reach for high care quality, information campaigns and development of workflows are indispensable for a successful implementation of a co-location of primary and emergency care.

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France

BACKGROUND

Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France.

METHOD

The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs.

RESULTS

Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density.

CONCLUSION

Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED.

The impact of general practitioners working in or alongside emergency departments: a rapid realist review

OBJECTIVES

Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak.

DESIGN

Rapid realist literature review.

SETTING

Emergency departments.

INCLUSION CRITERIA

Articles describing general practitioners working in or alongside emergency departments.

AIM

To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system.

RESULTS

Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes.

CONCLUSIONS

Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research.

PROSPERO REGISTRATION NUMBER

CRD42017069741.

Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms

INTRODUCTION

Increasing numbers of hospital emergency department (ED) visits pose a challenge to health systems in many countries. This paper aims to examine emergency and urgent care systems, in six countries and to identify reform trends in response to current challenges.

METHODS

Based on a literature review, six countries - Australia, Denmark, England, France, Germany and the Netherlands - were selected for analysis. Information was collected using a standardized questionnaire that was completed by national experts. These experts reviewed relevant policy documents and provided information on (1) the organization and planning of emergency and urgent care, (2) payment systems for EDs and urgent primary care providers, and (3) reform initiatives.

RESULTS

In the six countries four main reform approaches could be identified: (a) extending the availability of urgent primary care, (b) concentrating and centralizing the provision of urgent primary care, (c) improving coordination between urgent primary care and emergency care, and (d) concentrating emergency care provision at fewer institutions. The design of payment systems for urgent primary care and for emergency care is often aligned to support these reforms.

CONCLUSION

Better guidance of patients and a reconfiguration of emergency and urgent care are the most important measures taken to address the current challenges. Nationwide planning of all emergency care providers, closely coordinated reforms and informing patients can support future reforms.

Interventions to reduce emergency department utilisation: A review of reviews

OBJECTIVE

To describe policy interventions that have the objective to reduce ED use and to estimate their effectiveness.

METHODS

Narrative review by searching three electronic databases for scientific literature review papers published between 2010 and October 2015. The quality of the included studies was assessed with AMSTAR, and a narrative synthesis of the retrieved papers was applied.

RESULTS

Twenty-three included publications described six types of interventions: (1) cost sharing; (2) strengthening primary care; (3) pre-hospital diversion (including telephone triage); (4) coordination; (5) education and self-management support; (6) barriers to access emergency departments. The high number of interventions, the divergent methods used to measure outcomes and the different populations complicate their evaluation. Although approximately two-thirds of the primary studies showed reductions in ED use for most interventions the evidence showed contradictory results.

CONCLUSION

Despite numerous publications, evidence about the effectiveness of interventions that aim to reduce ED use remains insufficient. Studies on more homogeneous patient groups with a clearly described intervention and control group are needed to determine for which specific target group what type of intervention is most successful and how the intervention should be designed. The effective use of ED services in general is a complex and multi-factorial problem that requires integrated interventions that will have to be adapted to the specific context of a country with a feedback system to monitor its (un-)intended consequences. Yet, the co-location of GP posts and emergency departments seems together with the introduction of telephone triage systems the preferred interventions to reduce inappropriate ED visits while case-management might reduce the number of ED attendances by frequent ED users.

Healthcare use among preschool children attending GP-led urgent care centres: a descriptive, observational study

OBJECTIVE

Urgent care centres' (UCCs) hours were developed with the aim of reducing inappropriate emergency department (ED) attendances in England. We aimed to examine the presenting complaint and outcomes of care in 2 general practitioner (GP)-led UCCs with extended opening times.

DESIGN

Retrospective observational epidemiological study using routinely collected data.

SETTING

2 GP-led UCCs in London, colocated with a hospital ED.

PARTICIPANTS

All children aged under 5 years, attending 2 GP-led UCCs over a 3-year period.

OUTCOMES

Outcomes of care for the children including: primary diagnosis; registration status with a GP; destination following review within the UCC; and any medication prescribed. Comparison between GP-led UCC visit rates and routine general practices was also made.

RESULTS

3% (n=7747/282 947) of all attenders at the GP-led UCCs were children aged under 5 years. The most common reason for attendance was a respiratory illness (27%), followed by infectious illness (17%). 18% (n=1428) were either upper respiratory tract infections or viral infections. The majority (91%) of children attending were registered with a GP, and over two-thirds of attendances were 'out of hours'. Overall 79% were seen and discharged home. Preschool children were more likely to attend their GP (47.0 per 100) than a GP-led UCC (9.4 per 100; 95% CI 8.9 to 10.0).

CONCLUSIONS

Two-thirds of preschool children attending GP-led UCCs do so out of hours, despite the majority being registered with a GP. The case mix is comparable with those presenting to an ED setting, with the majority managed exclusively by the GPs in the UCC before discharge home. Further work is required to understand the benefits of a GP-led urgent system in influencing future use of services especially emergency care.