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General practitioners providing non-urgent care in emergency department: a natural experiment.

ABSTRACT: OBJECTIVE:To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators. DESIGN:Propensity score matched cohort study. SETTING:GPs in A&E colocated within the University Hospitals Coventry and Warwickshire NHS Trust between May 2015 and March 2016. PARTICIPANTS:Non-urgent attendances visits to the A&E department. MAIN OUTCOMES:Process outcomes (any investigation, any blood investigation, any radiological investigation, any intervention, admission and referrals) and A&E clinical indicators (spent 4?hours plus, left without being seen and 7-day reattendance). RESULTS:A total of 5426 patients seen by GPs in A&E were matched with 10?852 patients seen by emergency physicians (ratio 1:2). Compared with standard care in A&E, GPs in A&E significantly: admitted fewer patients (risk ratio (RR) 0.28, 95% CI 0.25 to 0.31), referred fewer patients to other specialists (RR 0.31, 95%?CI 0.24 to 0.40), ordered fewer radiological investigations (RR 0.38, 95%?CI 0.34 to 0.42), ordered fewer blood tests (0.57, 95%?CI 0.52 to 0.61) and ordered fewer investigations (0.93, 95%?CI 0.90 to 0.96). However, they intervened more, offered more primary care follow-up (RR 1.78, 95%?CI 1.67 to 1.89) and referred more patients to outpatient and other A&E clinics (RR 2.29, 95%?CI 2.10 to 2.49). Patients seen by GPs in A&E were on average less likely to spend 4?hours plus in A&E (RR 0.37, 95%?CI 0.30 to 0.45) compared with standard care in A&E. There was no difference in reattendance after 7?days (RR 0.96, 95%?CI 0.84 to 1.09). CONCLUSION:GPs in A&E tended to manage self-reporting minor cases with fewer resources than standard care in A&E, without increasing reattendance rates.

SUBMITTER: Uthman OA

PROVIDER: S-EPMC5950695 | biostudies-other | 2018 May

REPOSITORIES: biostudies-other

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General practitioners providing non-urgent care in emergency department: a natural experiment.

Uthman Olalekan A OA Walker Clare C Lahiri Sudakshina S Jenkinson David D Adekanmbi Victor V Robertson Wendy W Clarke Aileen A

BMJ open 20180510 5

<h4>Objective</h4>To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators.<h4>Design</h4>Propensity score matched cohort study.<h4>Setting</h4>GPs in A&E colocated within the University Hospitals Coventry and Warwickshire NHS Trust between May 2015 and March 2016.<h4>Participants</h4>Non-ur ...[more]

PMID: 29748341

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Project description:BACKGROUND:Lung cancer is the leading cause of cancer mortality in Australia. Guidelines suggest that patients with suspected lung cancer on thoracic imaging be referred for urgent specialist review. However, the term "suspected" is broad and includes the common finding of lung nodules, which often require periodic surveillance rather than urgent invasive investigation. The British Thoracic Society recommends that a lung nodule with a PanCan risk >?10% be considered for invasive investigation. This study aimed to assess which factors influence general practitioners (GPs) to request urgent review for a lung nodule and if these factors concur with PanCan risk prediction model variables. METHODS:A discrete choice experiment was developed that produced 32 individual case vignettes. Each vignette contained eight variables, four of which form the parsimonious PanCan risk prediction model. Two additional vignettes were created that addressed haemoptysis with a normal chest computed tomography (CT) scan and isolated mediastinal lymphadenopathy. The survey was distributed to 4160 randomly selected Australian GPs and they were asked if the patients in the vignettes required urgent (less than two weeks) specialist review. Multivariate logistic regression identified factors associated with request for urgent review. RESULTS:Completed surveys were received from 3.7% of participants, providing 152 surveys (1216 case vignettes) for analysis. The factors associated with request for urgent review were nodule spiculation (adj-OR 5.57, 95% CI 3.88-7.99, p?<?0.0001), larger nodule size, presentation with haemoptysis (adj-OR 4.79, 95% CI 3.05-7.52, p?<?0.0001) or weight loss (adj-OR 4.87, 95% CI 3.13-7.59, p?<?0.0001), recommendation for urgent review by the reporting radiologist (adj-OR 4.68, 95% CI 2.86-7.65, p?<?0.0001) and female GP gender (adj-OR 1.87, 95% CI 1.36-2.56, p 0.0001). In low risk lung nodules (PanCan risk <?10%), there was significant variability in perceived sense of urgency. Most GPs (83%) felt that a patient with haemoptysis and a normal chest CT scan did not require urgent specialist review but that a patient with isolated mediastinal lymphadenopathy did (75%). CONCLUSION:Future lung cancer investigation pathways may benefit from the addition of a risk prediction model to reduce variations in referral behavior for low risk lung nodules.

Project description:ObjectiveTo determine the association between a large-scale, multi-payer primary care redesign-the Comprehensive Primary Care (CPC) Initiative-on outpatient emergency department (ED) and urgent care center (UCC) use and to identify the types of visits that drive the overall trends observed.Data sourcesMedicare claims data capturing characteristics and outcomes of 565 674 Medicare fee-for-service (FFS) beneficiaries attributed to 497 CPC practices and 1 165 284 beneficiaries attributed to 908 comparison practices.Study designWe used an adjusted difference-in-differences framework to test the association between CPC and beneficiaries' ED and UCC use from October 2012 through December 2016. Regression models controlled for baseline practice and patient characteristics and practice-level clustering of standard errors. Our key outcomes were all-cause and primary care substitutable (PC substitutable) outpatient ED and UCC visits, and potentially primary care preventable (PPC preventable) ED visits, categorized by the New York University Emergency Department Algorithm. We used a propensity score-matched comparison group of practices that were similar to CPC practices before CPC on multiple dimensions. Both groups of practices had similar growth in ED and UCC visits in the two-year period before CPC.Principal findingsComprehensive Primary Care practices had 2% (P = .06) lower growth in all-cause ED visits than comparison practices. They had 3% (P = .02) lower growth in PC substitutable ED visits, driven by lower growth in weekday PC substitutable visits (4%, P = .002). There was 3% (P = .04) lower growth in PPC preventable ED visits with no weekday/nonweekday differential. As expected, our falsification test showed no difference in ED visits for injuries. UCC visits had 9% lower growth for both all-cause (P = .08) and PC substitutable visits (P = .07).ConclusionsOur results suggest that greater access to the practice and more effective primary care both contributed to the lower growth in ED and UCC visits during the initiative.

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General practitioners providing non-urgent care in emergency department: a natural experiment.

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General practitioners providing non-urgent care in emergency department: a natural experiment.

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