Closing five Emergency Departments in England between 2009 and 2011: the closED controlled interrupted time-series analysis

A systematic review case study of urgent and emergency care configuration found citation searching of Web of Science and Google Scholar of similar value

BACKGROUND

Supplementary search methods, including citation searching, are essential if systematic reviews are to avoid producing biased conclusions. Little evidence exists on how to prioritise databases for citation searching or to establish whether using multiple sources is beneficial.

OBJECTIVES

A systematic review examining urgent and emergency care reconfiguration was used to investigate the utility of citation searching on Web of Science (WOS) and/or Google Scholar (GS).

METHODS

This case study investigated numbers of studies, additional studies and unique studies retrieved from both sources. In addition, the time to search, the ease of adding references to reference management software and obtaining abstracts of studies for screening are briefly considered.

RESULTS

WOS retrieved 62 references after deduplication of the results, 52 being additional references not retrieved during the database searching. GS retrieved 134 unique references with 63 additional references. WOS and GS retrieved the same three additional included studies. WOS was less time intensive to search given the facility to restrict to English language papers and availability of abstracts.

CONCLUSIONS

In a single systematic review case study, citation searching was required to identify all included studies. Citation searching on WOS is more efficient, where a subscription is available. Both databases identified the same studies but GS required additional time to remove non-English language studies and locate abstracts.

Effects of increased distance to urgent and emergency care facilities resulting from health services reconfiguration: a systematic review

Background

Service reconfigurations sometimes increase travel time and/or distance for patients to reach their nearest hospital or other urgent and emergency care facility. Many communities value their local services and perceive that proposed changes could worsen outcomes for patients.

Objectives

To identify, appraise and synthesise existing research evidence regarding the outcomes and impacts of service reconfigurations that increase the time and/or distance for patients to reach an urgent and emergency care facility. We also aimed to examine the available evidence regarding associations between distance to a facility and outcomes for patients and health services, together with factors that may influence (moderate or mediate) these associations.

Data sources

We searched seven bibliographic databases in February 2019. The search was supplemented by citation-tracking and reference list checking. A separate search was conducted to identify the current systematic reviews of telehealth to support urgent and emergency care.

Methods

Brief inclusion and exclusion criteria were as follows: (1) population – adults or children with conditions that required emergency treatment; (2) intervention/comparison – studies comparing outcomes before and after a service reconfiguration, which affects the time/distance to urgent and emergency care or comparing outcomes in groups of people travelling different distances to access urgent and emergency care; (3) outcomes – any patient or health system outcome; (4) setting – the UK and other developed countries with relevant health-care systems; and (5) study design – any. The search results were screened against the inclusion criteria by one reviewer, with a 10% sample screened by a second reviewer. A quality (risk-of-bias) assessment was undertaken using The Joanna Briggs Institute Checklist for Quasi-Experimental Studies. We performed a narrative synthesis of the included studies and assessed the overall strength of evidence using a previously published method.

Results

We included 44 studies in the review, of which eight originated from the UK. For studies of general urgent and emergency care populations, there was no evidence that reconfiguration that resulted in increased travel time/distance affected mortality rates. By contrast, evidence of increased risk was identified from studies restricted to patients with acute myocardial infarction. Increases in mortality risk were most obvious within the first 1–4 years after reconfiguration. Evidence for other conditions was inconsistent or very limited. In the absence of reconfiguration, evidence mainly from cohort studies indicated that increased travel time or distance is associated with increased mortality risk for the acute myocardial infarction and trauma populations, whereas for obstetric emergencies the evidence was inconsistent. We included 12 systematic reviews of telehealth. Meta-analyses suggested that telehealth technologies can reduce time to treatment for people with stroke and ST elevation myocardial infarction.

Limitations

Most studies came from non-UK settings and many were at high risk of bias because there was no true control group. Most review processes were carried out by a single reviewer within a constrained time frame.

Conclusions

We found no evidence that increased distance increases mortality risk for the general population of people requiring urgent and emergency care, although this may not be true for people with acute myocardial infarction or trauma. Increases in mortality risk were most likely in the first few years after reconfiguration.

Future work

Research is needed to better understand how health systems plan for and adapt to increases in travel time, to quantify impacts on health system outcomes, and to address the uncertainty about how risk increases with distance in circumstances relevant to UK settings.

Study registration

This study is registered as PROSPERO CRD42019123061.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 31. See the NIHR Journals Library website for further project information.

Effects of service changes affecting distance/time to access urgent and emergency care facilities on patient outcomes: a systematic review

BACKGROUND

Reconfiguration of urgent and emergency care services often increases travel time/distance for patients to reach an appropriate facility. Evidence of the effects of reconfiguration is important for local communities and commissioners and providers of health services.

METHODS

We performed a systematic review of the evidence regarding effects of service reconfigurations that increase the time/distance for some patients to reach an urgent and emergency care (UEC) facility. We searched seven bibliographic databases from 2000 to February 2019 and used citation tracking and reference lists to identify additional studies. We included studies of any design that compared outcomes for people with conditions requiring emergency treatment before and after service reconfiguration with an associated change in travel time/distance to access UEC. Studies had to be conducted in the UK or other developed countries. Data extraction and quality assessment (using the Joanna Briggs Institute checklist for quasi-experimental studies) were undertaken by a single reviewer with a sample checked for accuracy and consistency. We performed a narrative synthesis of the included studies. Overall strength of evidence was assessed using a previously published method that considers volume, quality and consistency.

RESULTS

We included 12 studies, of which six were conducted in the USA, two in the UK and four in other European countries. The studies used a variety of observational designs, with before-after and cohort designs being most common. Only two studies included an independent control site/sites where no reconfiguration had taken place. The reconfigurations evaluated in these studies reported relatively small effects on average travel times/distance.

DISCUSSION

For studies of general UEC populations, there was no convincing evidence as to whether reconfiguration affected mortality risk. However, evidence of increased risk was identified from studies of patients with acute myocardial infarction, particularly 1 to 4 years after reconfiguration. Evidence for other conditions was inconsistent or very limited.

CONCLUSIONS

We found insufficient evidence to determine whether increased distance to UEC increases mortality risk for the general population of people requiring UEC, although this conclusion may not extend to people with specific conditions.

Impact of emergency care centralisation on mortality and efficiency: a retrospective service evaluation

Objective

Evidence favours centralisation of emergency care for specific conditions, but it remains unclear whether broader implementation improves outcomes and efficiency. Routine healthcare data examined consolidation of three district general hospitals with mixed medical admission units (MAU) into a single high-volume site directing patients from the ED to specialty wards with consultant presence from 08:00 to 20:00.

Methods

Consecutive unscheduled adult index admissions from matching postcode areas were identified retrospectively in Hospital Episode Statistics over a 3-year period: precentralisation baseline (from 16 June 2014 to 15 June 2015; n=18 586), year 1 postcentralisation (from 16 June 2015 to 15 June 2016; n=16 126) and year 2 postcentralisation (from 16 June 2016 to 15 June 2017; n=17 727). Logistic regression including key demographic covariates compared baseline with year 1 and year 2 probabilities of mortality and daily discharge until day 60 after admission and readmission within 60 days of discharge.

Results

Relative to baseline, admission postcentralisation was associated with favourable OR (95% CI) for day 60 mortality (year 1: 0.95 (0.88 to 1.02), p=0.18; year 2: 0.94 (0.91 to 0.97), p<0.01), mainly among patients aged 80+ years (year 1: 0.88 (0.79 to 0.97); year 2: 0.91 (0.87 to 0.96)). The probability of being discharged alive on any day since admission increased (year 1: 1.07 (1.04 to 1.10), p<0.01; year 2: 1.04 (1.02 to 1.05), p<0.01) and the risk of readmission decreased (year 1: 0.90 (0.87 to 0.94), p<0.01; year 2: 0.92 (0.90 to 0.94), p<0.01).

Conclusion

A centralised site providing early specialist care was associated with improved short-term outcomes and efficiency relative to lower volume ED admitting to MAU, particularly for older patients.

The impact of closing emergency departments on mortality in emergencies: an observational study

BACKGROUND

In England the demand for emergency care is increasing, while there is also a staffing shortage. This has implications for quality of care and patient safety. One solution may be to concentrate resources on fewer sites by closing or downgrading emergency departments (EDs). Our aim was to quantify the impact of such reorganisation on population mortality.

METHODS

We undertook a controlled interrupted time series analysis to detect the impact of closing or downgrading five EDs, which occurred due to concerns regarding sustainability. We obtained mortality data from 2007 to 2014 using national databases. To establish ED resident catchment populations, estimated journey times by road were supplied by the Department for Transport. Other major changes in the emergency and urgent care system were determined by analysis of annual NHS Trust reports in each geographical area studied. Our main outcome measures were mortality and case fatality for a set of 16 serious emergency conditions.

RESULTS

For residents in the areas affected by closure, journey time to the nearest ED increased (median change 9 min, range 0-25 min). We found no statistically reliable evidence of a change in overall mortality following reorganisation of ED care in any of the five areas or overall (+2.5% more deaths per month on average; 95% CI -5.2% to +10.2%; p=0.52). There was some evidence to suggest that, on average across the five areas, there was a small increase in case fatality, an indicator of the 'risk of death' (+2.3%, 95% CI +0.9% to+3.6%; p<0.001), but this may have arisen due to changes in hospital admissions.

CONCLUSIONS

We found no evidence that reorganisation of emergency care was associated with a change in population mortality in the five areas studied. Further research should establish the economic consequences and impact on patient experience and neighbouring hospitals.

An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015

OBJECTIVES

To understand the impact of emergency department (ED) reconfiguration on the number of patients waiting for hospital beds on trolleys in the remaining EDs in four geographical regions in Ireland using time-series analysis.

SETTING

EDs in four Irish regions; the West, North-East, South and Mid-West from 2005 to 2015.

PARTICIPANTS

All patients counted as waiting on trolleys in an ED for a hospital bed in the study hospitals from 2005 to 2015.

INTERVENTION

The system intervention was the reconfiguration of ED services, as determined by the Department of Health and Health Service Executive. The timing of these interventions varied depending on the hospital and region in question.

RESULTS

Three of the four regions studied experienced a significant change in ED trolley numbers in the 12-month post-ED reconfiguration. The trend ratio before and after the intervention for these regions was as follows: North-East incidence rate ratio (IRR) 2.85 (95% CI 2.04 to 3.99, p<0.001), South IRR 0.68 (95% CI 0.51 to 0.89, p=0.006) and the Mid-West IRR 0.03 (95% 1.03 to 2.03, p=0.03). Two of these regions, the South and the Mid-West, displayed a convergence between the observed and expected trolley numbers in the 12-month post-reconfiguration. The North-East showed a much steeper increase, one that extended beyond the 12-month period post-ED reconfiguration.

CONCLUSIONS

Findings suggest that the impacts of ED reconfiguration on regional level ED trolley trends were either non-significant or caused a short-term shock which converged on the pre-reconfiguration trend over the following 12 months. However, the North-East is identified as an exception due to increased pressures in one regional hospital, which caused a change in trend beyond the 12-month post reconfiguration.