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.
Bibliographical noteFunding Information:
Acknowledgements Work as part of the evaluation of the Best Care, Anywhere: Integrating Primary Care in Coventry Programme, which was essentially a collaborative effort between the Coventry–Rugby GP Alliance, the University Hospital Coventry and Warwickshire and academic partners, the University of Warwick, Coventry University and University of Birmingham. We would like to take this opportunity to express our gratitude to all members of the Coventry–Rugby GP Alliance Steering Group for their thoughtful discussions with the research team regarding the multifaceted nature of the challenges currently facing the primary and acute care sectors in the region. We also gratefully acknowledge the contributions of University Hospital Coventry and Warwickshire for their efforts in sharing hospital activity data with the research team which made this study possible. Dr Wendy Robertson, Dr Victor Adekanmbi, Dr David Jenkinson and Professor Aileen Clarke are partly funded by the NIHR CLAHRC West Midlands initiative. Dr Clare Walker holds an NIHR funded ACF post. Dr Olalekan A. Uthman is supported by the National Institute of Health Research using Official Development Assistance (ODA) funding. This report presents independent research and the views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018.
- four hour delay
- general practitioners
- natural experiment
- propensity score