Characteristics of general practices associated with emergency-department attendance rates: a cross-sectional study

Incidence of short-term community hospital stays and clinical profiles of patients: the Finnish Community Hospital Cohort Study

OBJECTIVE

A community hospital system covers the entire population of Finland. Yet there is little research on the system beyond routine statistics. More knowledge is needed on the incidence of hospital stays and patient profiles. We investigated the incidence of short-term community hospital stays and the features of care and patients.

DESIGN

Prospective observational study.

SETTING

Community hospitals in the catchment area of Kuopio University Hospital in Finland.

SUBJECTS

Short-term (up to one month) community hospital stays of adult residents.

MAIN OUTCOME MEASURES

The outcome was the incidence rate of short-term community hospital stays according to age, sex and the first underlying diagnoses.

RESULTS

A number of 13,482 short-term community hospital stays were analyzed. The patients' mean age was 77 years. The incidence rate of short-term hospital stays was 28.6 stays per 1000 person-years among residents aged <75 years and 419.0 among residents aged ≥75 years. In men aged <75 years, the hospital stay incidence was about 40% higher than in women of the same age but in residents aged ≥75 years incidences did not differ between sexes. The most common diagnostic categories were vascular and respiratory diseases, injuries and mental illnesses.

CONCLUSIONS

The incidence rate of short-term community hospital stays increased sharply with age and was highest among women aged ≥75 years. Care was required for acute and chronic conditions common in older adults.

IMPLICATIONS

Community hospitals have a substantial role in hospital care of older adults.

The impact of collaborative organisational models and general practice size on patient safety and quality of care in the English National Health Service: A systematic review

Collaborative primary care has become an increasingly popular strategy to manage existing pressures on general practice. In England, the recent changes taking place in the primary care sector have included the formation of collaborative organisational models and a steady increase in practice size. The aim of this review was to summarise the available evidence on the impact of collaborative models and general practice size on patient safety and quality of care in England. We searched for quantitative and qualitative studies on the topic published between January 2010 and July 2023. The quality of articles was assessed using the Newcastle-Ottawa Scale and the Critical Appraisal Skills Programme checklist. We screened 6533 abstracts, with full-text screening performed on 76 records. A total of 29 articles were included in the review. 19 met the inclusion criteria following full-text screening, with seven identified through reverse citation searching and three through expert consultation. All studies were found to be of moderate or high quality. A predominantly positive impact on service delivery measures and patient-level outcomes was identified. Meanwhile, the evidence on the effect on pay-for-performance outcomes and hospital admissions is mixed, with continuity of care and access identified as a concern. While this review is limited to evidence from England, the findings provide insights for all health systems undergoing a transition towards collaborative primary care.

Impact of a case-management intervention for reducing emergency attendance on primary care: randomised control trial

BACKGROUND

The impact on primary care workload of case-management interventions to reduce emergency department (ED) attendances is unknown.

AIM

To examine the impact of a telephone-based case-management intervention targeting people with high ED attendance on primary care use.

DESIGN AND SETTING

A single-site data extract from a larger randomised control trial, using the patient-level data from primary care electronic health records (2015-2020), was undertaken.

METHOD

A total of 363 patients at high risk of ED usage were randomised to receive a 6-month case-management intervention (253 patients) or standard care (110 patients). Poisson regression models were used to calculate monthly rates of primary care use over time for the 2 years post-randomisation, comparing both arms. Usage was subclassified into face-to-face, telephone, letter, and community and secondary care referrals, stratified by patient demographics.

RESULTS

No significant difference was found in the mean annual rate of primary care events between the intervention and control arms (P = 0.70). Secondary care referrals saw a 26% reduction in the mean annual referral rate (incident rate ratio [IRR] 0.74, 95% confidence interval [CI] = 0.64 to 0.86, P<0.001) and letters sent increased by 6% in the intervention arm compared with the control arm (IRR 1.06, 95% CI = 1.01 to 1.11, P = 0.01). In the case-managed arm, in patients aged ≥80 years there was a 33% increase in primary care usage (IRR 1.33, 95% CI = 1.28 to 1.40, P<0.001); with a corresponding 10% decrease in patients aged <80 years when compared with controls (IRR 0.90, 95% CI = 0.87 to 0.92, P<0.001).

CONCLUSION

A targeted case-management intervention to reduce ED attendances did not increase overall primary care use. Redistribution of usage is seen among some patient groups, particularly older people, which may have important implications for primary healthcare planning.

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

BACKGROUND

Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere.

AIM

To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality.

DESIGN AND SETTING

Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs.

METHOD

Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses.

RESULTS

Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years.

CONCLUSION

Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.

Factors influencing general practitioners decisions to refer Paediatric patients to the emergency department: a systematic review and narrative synthesis

BACKGROUND

Clinical guidelines are integral to a general practitioner's decision to refer a paediatric patient to emergency care. The influence of non-clinical factors must also be considered. This review explores the non-clinical factors that may influence general practitioners (GPs) when deciding whether or not to refer a paediatric patient to the Emergency Department (ED).

METHODS

A systematic review of peer-reviewed literature published from August 1980 to July 2019 was conducted to explore the non-clinical factors that influence GPs' decision-making in referring paediatric patients to the emergency department. The results were synthesised using a narrative approach.

RESULTS

Seven studies met the inclusion criteria. Non-clinical factors relating to patients, GPs and health systems influence GPs decision to refer children to the ED. GPs reported parents/ caregivers influence, including their perception of severity of child's illness, parent's request for onward referral and GPs' appraisal of parents' ability to cope. Socio-economic status, GPs' aversion to risk and system level factors such as access to diagnostics and specialist services also influenced referral decisions.

CONCLUSIONS

A myriad of non-clinical factors influence GP referrals of children to the ED. Further research on the impact of non-clinical factors on clinical decision-making can help to elucidate patterns and trends of paediatric healthcare and identify areas for intervention to utilise resources efficiently and improve healthcare delivery.

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background

Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.

Objectives

We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.

Design and setting

We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.

Participants

Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.

Interventions

Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).

Main outcome measures

Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.

Results

Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.

Limitations

There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.

Conclusions

Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.

Future work

Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

What Is the Optimal Primary Care Panel Size?: A Systematic Review

BACKGROUND

Primary care for a panel of patients is a central component of population health, but the optimal panel size is unclear.

PURPOSE

To review evidence about the association of primary care panel size with health care outcomes and provider burnout.

DATA SOURCES

English-language searches of multiple databases from inception to October 2019 and Google searches performed in September 2019.

STUDY SELECTION

English-language studies of any design, including simulation models, that assessed the association between primary care panel size and safety, efficacy, patient-centeredness, timeliness, efficiency, equity, or provider burnout.

DATA EXTRACTION

Independent, dual-reviewer extraction; group consensus rating of certainty of evidence.

DATA SYNTHESIS

Sixteen hypothesis-testing studies and 12 simulation modeling studies met inclusion criteria. All but 1 hypothesis-testing study were cross-sectional assessments of association. Three studies each provided low-certainty evidence that increasing panel size was associated with no or modestly adverse effects on patient-centered and effective care. Eight studies provided low-certainty evidence that increasing panel size was associated with variable effects on timely care. No studies assessed the effect of panel size on safety, efficiency, or equity. One study provided very-low-certainty evidence of an association between increased panel size and provider burnout. The 12 simulation studies evaluated 5 models; all used access as the only outcome of care. Five and 2 studies, respectively, provided moderate-certainty evidence that adjusting panel size for case mix and adding clinical conditions to the case mix resulted in better access.

LIMITATION

No studies had concurrent comparison groups, and published and unpublished studies may have been missed.

CONCLUSION

Evidence is insufficient to make evidence-based recommendations about the optimal primary care panel size for achieving beneficial health outcomes.

PRIMARY FUNDING SOURCE

Veterans Affairs Quality Enhancement Research Initiative.

Predictors of emergency department and GP use among patients with mental health conditions: a public health survey

BACKGROUND

High demand for health services is an issue of current importance in England, in part because of the rapidly increasing use of emergency departments (EDs) and GP practices for mental health conditions and the high cost of these services.

AIM

To examine the social determinants of health service use in people with mental health issues.

DESIGN AND SETTING

Twenty-eight neighbourhoods, each with a population of 5000-10 000 people, in the north west coast of England with differing levels of deprivation.

METHOD

A comprehensive public health survey was conducted, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. Poisson regression models assessed the effect of mental health comorbidity, mental and physical health comorbidity, and individual mental health symptoms on ED and general practice attendances, adjusting for relevant socioeconomic and lifestyle factors.

RESULTS

Participants who had both a physical and mental health condition reported attending the ED (rate ratio [RR] = 4.63, 95% confidence interval [CI] = 2.86 to 7.51) and general practice (RR = 3.82, 95% CI = 3.16 to 4.62) more frequently than all other groups. Having a higher number of mental health condition symptoms was associated with higher general practice and ED service use. Depression was the only mental health condition symptom that was significantly associated with ED attendance (RR = 1.41, 95% CI = 1.05 to 1.90), and anxiety was the only symptom significantly associated with GP attendance (RR = 1.19, 95% CI = 1.03 to 1.38).

CONCLUSION

Mental health comorbidities increase the risk of attendances to both EDs and general practice. Further research into the social attributes that contribute to reduced ED and general practice attendance rates is needed.

The influence of general practitioners on access points to health care in a system without gatekeeping: a cross-sectional study in the context of the QUALICOPC project in Austria

AIM

To assess the rates of specialist visits and visits to hospital emergency departments (ED) among patients in Austria with and without concurrent general practitioner (GP) consultation and among patients with and without chronic disease.

METHODS

The cross-sectional questionnaire study was conducted in the context of the QUALICOPC project in 2012. Fieldworkers recruited 1596 consecutive patients in 184 GP offices across Austria. The 41-question survey addressed patients' experiences with regard to access to, coordination, and continuity of primary care, as well demographics and health status. Descriptive statistics as well as univariate and multivariate regression models were applied.

RESULTS

More than 90% of patients identified a GP as a primary source of care. Among all patients, 85.5% reported having visited a specialist and 26.4% the ED at least once in the previous year. Having a usual GP did not change the rate of specialist visits. Additionally, patients with chronic disease had a higher likelihood of presenting to the ED despite having a GP as a usual source of care.

CONCLUSION

Visiting specialists in Austria is quite common, and the simple presence of a GP as a usual source of care is insufficient to regulate pathways within the health care system. This can be particularly difficult for chronic care patients who often require care at different levels of the system and show higher frequency of ED presentations.

Understanding people who self-referred in an emergency department with primary care problems during office hours: a qualitative interview study at a Daytime General Practice Cooperative in two hospitals in The Hague, The Netherlands

OBJECTIVE

To provide insight into the motives for hospital self-referral during office hours and the barriers deterring general practitioner (GP) consultation with a primary care request.

SETTING

People who self-referred at a Daytime General Practice Cooperative (GPC) in two hospitals in The Hague, The Netherlands.

PARTICIPANTS

A total of 44 people who self-referred were interviewed in two hospitals. The average age of interviewees was 35 years (range 19 months to 83 years), a parent of a young patient was interviewed, but the age of patients is shown here. There were more male patients (66%) than female patients (34%). Patients were recruited using a sampling method after triage. Triage was the responsibility of an emergency department (ED) nurse in one hospital and of a GP in the other. Those excluded from participation included (a) children under the age of 18 years and not accompanied by a parent or legal guardian, (b) foreign patients not resident in the Netherlands, (c) patients unable to communicate in Dutch or English and (d) patients directly referred to the ED after triage by the GP (in one hospital).

RESULTS

People who self-referred generally reported several motives for going to the hospital directly. Information and awareness factors played an important role, often related to a lack of information regarding where to go with a medical complaint. Furthermore, many people who self-referred mentioned hospital facilities, convenience and perceived medical necessity as motivational factors. Barriers deterring a visit to the own GP were mainly logistical, including not being registered with a GP, the GP was too far away, poor GP telephone accessibility or a waiting list for an appointment.

CONCLUSION

Information and awareness factors contribute to misperceptions among people who self-referred concerning the complaint, the GP and the hospital. As a range of motivational factors are involved, there is no straightforward solution. However, better dissemination of information might alleviate misconceptions and contribute to providing the right care to the right patient in the right setting.

Social gradients in health and social care costs: Analysis of linked electronic health records in Kent, UK

OBJECTIVES

Research into the socio-economic patterning of health and social care costs in the UK has so far been limited to examining only particular aspects of healthcare. In this study, we explore the social gradients in overall healthcare and social care costs, as well as in the disaggregated costs by cost category.

STUDY DESIGN

We calculated the social gradient in health and social care costs by cost category using a linked electronic health record data set for Kent, a county in South East England. We performed a cross-sectional analysis on a sample of 323,401 residents in Kent older than 55 years to assess the impact of neighbourhood deprivation on mean annual per capita costs in 2016/17.

METHODS

Patient-level costs were estimated from activity data for the financial year 2016/17 and were extracted alongside key patient characteristics. Mean costs were calculated for each area deprivation quintile based on the index of multiple deprivation of the neighbourhood (lower super output area) in which the patient lived. Cost subcategories were analysed across primary care, secondary care, social care, community care and mental health.

RESULTS

The mean annual per capita cost increased with deprivation across each deprivation quintile, with a cost of £1205 in the most affluent quintile, compared with £1623 in the most deprived quintile, a 35% cost increase. Social gradients were found across all cost subcategories.

CONCLUSIONS

Health inequalities in the population older than 55 years in Kent are associated with health and social care costs of £109m, equivalent to 15% of the estimated total expenditure in this age group. Such significant costs suggest that appropriate interventions to reduce socio-economic inequalities have the potential to substantially improve population health and, depending on how much investment they require, may even result in cost savings.

Area deprivation and attachment to a general practitioner through centralized waiting lists: a cross-sectional study in Quebec, Canada

BACKGROUND

Access to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists.

METHODS

A cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients' socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs.

RESULTS

Patients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas.

CONCLUSION

Our findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities.

Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England

OBJECTIVE

To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI).

DESIGN, SETTING, PARTICIPANTS

Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database.

OUTCOMES AND ANALYSIS

Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC).

RESULTS

Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews.

CONCLUSIONS

Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.

Patient experience of general practice and use of emergency hospital services in England: regression analysis of national cross-sectional time series data

BACKGROUND

The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England.

METHODS

The study included 8124 general practices between 2011-2012 and 2013-2014. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours and overall experience (on 0-100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification.

RESULTS

Mean practice-level rates of A&E visits and emergency admissions increased from 2011-2012 to 2013-2014 (310.3-324.4 and 98.8-102.9 per 1000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011-2012 and 76.6 in 2013-2014. In the adjusted regression analysis, an SD increase in experience of making appointments (equal to 9 points) predicted decreases of 1.8% (95% CI -2.4% to -1.2%) in A&E visit rates and 1.4% (95% CI -1.9% to -0.9%) in admission rates. This equalled 301 174 fewer A&E visits and 74 610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses.

CONCLUSIONS

Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E visits and emergency admissions.

Population and patient factors affecting emergency department attendance in London: retrospective cohort analysis of linked primary and secondary care records

BACKGROUND

Population factors, including social deprivation and morbidity, predict the use of emergency departments (EDs).

AIM

To link patient-level primary and secondary care data to determine whether the association between deprivation and ED attendance is explained by multimorbidity and other clinical factors in the GP record.

DESIGN AND SETTING

Retrospective cohort study based in East London.

METHOD

Primary care demographic, consultation, diagnostic, and clinical data were linked with ED attendance data. GP Patient Survey (GPPS) access questions were linked to practices.

RESULTS

Adjusted multilevel analysis for adults showed a progressive rise in ED attendance with increasing numbers of long-term conditions (LTCs). Comparing two LTCs with no conditions, the odds ratio (OR) is 1.28 (95% confidence interval [CI] = 1.25 to 1.31); comparing four or more conditions with no conditions, the OR is 2.55 (95% CI = 2.44 to 2.66). Increasing annual GP consultations predicted ED attendance: comparing zero with more than two consultations, the OR is 2.44 (95% CI = 2.40 to 2.48). Smoking (OR 1.30, 95% CI = 1.28 to 1.32), being housebound (OR 2.01, 95% CI = 1.86 to 2.18), and age also predicted attendance. Patient-reported access scores from the GPPS were not a significant predictor. For children, younger age, male sex, white ethnicity, and higher GP consultation rates predicted attendance.

CONCLUSION

Using patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.

Exploring the relationship between general practice characteristics and attendance at Walk-in Centres, Minor Injuries Units and Emergency Departments in England 2009/10-2012/2013: a longitudinal study

BACKGROUND

The UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates.

METHODS

A longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients' emergency attendance rates and patients' reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time.

RESULTS

Practice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (-0.26 per 1% increase, 95%CI -0.45 to -0.08).

CONCLUSION

Practices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use.

Socioeconomic deprivation and accident and emergency attendances: cross-sectional analysis of general practices in England

BACKGROUND

Demand for England's accident and emergency (A&E) services is increasing and is particularly concentrated in areas of high deprivation. The extent to which primary care services, relative to population characteristics, can impact on A&E is not fully understood.

AIM

To conduct a detailed analysis to identify population and primary care characteristics associated with A&E attendance rates, particularly those that may be amenable to change by primary care services.

DESIGN AND SETTING

This study used a cross-sectional population-based design. The setting was general practices in England, in the year 2011-2012.

METHOD

Multivariate linear regression analysis was used to create a model to explain the variability in practice A&E attendance rates. Predictor variables included population demographics, practice characteristics, and measures of patient experiences of primary care.

RESULTS

The strongest predictor of general practice A&E attendance rates was social deprivation: the Index of Multiple Deprivation (IMD-2010) (β = 0.3. B = 1.4 [95% CI =1.3 to 1.6]), followed by population morbidity (GPPS responders reporting a long-standing health condition) (β = 0.2, B = 231.5 [95% CI = 202.1 to 260.8]), and knowledge of how to contact an out-of-hours GP (GPPS question 36) (β = -0.2, B = -128.7 [95% CI =149.3 to -108.2]). Other significant predictors included the practice list size (β = -0.1, B = -0.002 [95% CI = -0.003 to -0.002]) and the proportion of patients aged 0-4 years (β = 0.1, B = 547.3 [95% CI = 418.6 to 676.0]). The final model explained 34.4% of the variation in A&E attendance rates, mostly due to factors that could not be modified by primary care services.

CONCLUSION

Demographic characteristics were the strongest predictors of A&E attendance rates. Primary care variables that may be amenable to change only made a small contribution to higher A&E attendance rates.

Exploring the relationship between general practice characteristics, and attendance at walk-in centres, minor injuries units and EDs in England 2012/2013: a cross-sectional study

BACKGROUND

For several years, EDs in the UK NHS have faced considerable increases in attendance rates. Walk-in centres (WiCs) and minor injuries units (MIUs) have been suggested as solutions. We aimed to investigate the associations between practice and practice population characteristics with ED attendance rates or combined ED/WiC/MIU attendance, and the associations between WiC/MIU and ED attendance.

METHODS

We used general practice-level data including 7462 English practices in 2012/2013 and present adjusted regression coefficients from linear multivariable analysis for relationships between patients' emergency attendance rates and practice characteristics.

RESULTS

Every percentage-point increase in patients reporting inability to make an appointment was associated with an increase in emergency attendance by 0.36 (95% CI 0.06 to 0.66) per 1000 population. Percentage-point increases in patients unable to speak to a general practitioner (GP)/nurse within two workdays and patients able to speak often to their preferred GP were associated with increased emergency attendance/1000 population by 0.23 (95% CI 0.05 to 0.42) and 0.10 (95% CI 0.00 to 0.19), respectively. Practices in areas encompassing several towns (conurbations) had higher attendance than rural practices, as did practices with more non-UK-qualified GPs. Practice population characteristics associated with increased emergency attendance included higher unemployment rates, higher percentage of UK whites and lower male life expectancy, which showed stronger associations than practice characteristics. Furthermore, higher MIU or WiC attendance rates were associated with lower ED attendance rates.

CONCLUSIONS

Improving availability of appointments and opportunities to speak a GP/nurse at short notice might reduce ED attendance. Establishing MIUs and WiCs might also reduce ED attendance.

Interpersonal continuity of care and type two diabetes

INTRODUCTION

Continuity of care is one of the core principles of primary care. The importance of interpersonal continuity in treating diabetic patients is unclear.

AIM

To examine the association of interpersonal continuity of care, by the primary care physician, on the process of diabetic care and on health end points including diabetes control, hospital admissions and mortality.

METHODS

We conducted a population based cohort study, 23,294 eligible participants were identified in Clalit Health Services Central Region at January 1, 2011 and followed through to December 31, 2012. Multivariate logistic regression models were applied to the data to study simultaneously the independent relationship between low interpersonal continuity, adjusted for background characteristics, and outcomes of care, including hospitalization and mortality.

RESULTS

Achieving clinical targets was more likely in the high interpersonal continuity group HBA1 C OR 1.11 (CI 1.04-1.19), blood pressure OR 1.12 (1.04-1.20), LDL OR 1.14 (1.06-1.22). Patients with high interpersonal continuity had lower odds for mortality OR 0.59 (0.50-0.70). Admissions to hospital were lower in the high interpersonal continuity group, OR 0.82 (0.75-0.90), however when adjusting for background characteristics the difference in OR for hospital admissions became non-significant 0.92 (0.84-1.01).

CONCLUSION

High interpersonal continuity was associated with improved outcomes of process, and both primary and secondary clinical targets amongst adult patients with diabetes. This study is the first to find an association between interpersonal continuity and mortality amongst adults with diabetes.

Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK

BACKGROUND AND OBJECTIVE

Demand for unplanned hospital services is rising, and children are frequent users, especially where access to primary care is poor. In England, universal health care coverage entitles parents to see a general practitioner (GP) for first-contact care. However, access to GP appointments is variable, and few patients can see their own regular GP out of hours (OOH). The goal of this study explored the association between access to GPs , emergency department (ED) visits and short hospitalizations (<2 days) in children in England.

METHODS

ED visit and short hospitalization rates were investigated in 9.5 million children aged <15 years registered with English family practices between April 2011 and March 2012 by using administrative hospital data. Six access categories ranked all practices according to patients' reported ability to schedule GP appointments; from national GP Patient Survey data. GP consulting hours were 8:00 am to 6:30 pm on weekdays.

RESULTS

There were 3 074 616 ED visits (56% OOH) and 470 752 short hospitalizations over the 12 months studied. Children registered with practices in the highest access group compared with the lowest were 9% less likely to visit an ED (adjusted rate ratio: 0.91 [95% confidence interval: 0.89-93]), particularly OOH compared with consulting hours (10% vs 7%). Children in the highest access groups were equally likely to be admitted for a short stay.

CONCLUSIONS

Increasing GP accessibility might alleviate the burden of ED visits from children, particularly during peak times OOH. Short hospitalizations may be more sensitive to other aspects of health systems.

Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario, Canada

PURPOSE

The purpose of this study was to determine the relationship between the number of patients under a primary care physician's care (panel size) and primary care quality indicators.

METHODS

We conducted a cross-sectional, population-based study of fee-for-service and capitated interprofessional and non-interprofessional primary health care practices in Ontario, Canada between April 2008 and March 2010, encompassing 4,195 physicians with panel sizes ≥1,200 serving 8.3 million patients. Data was extracted from multiple linked, health-related administrative databases and covered 16 quality indicators spanning 5 dimensions of care: access, continuity, comprehensiveness, and evidence-based indicators of cancer screening and chronic disease management.

RESULTS

The likelihood of being up-to-date on cervical, colorectal, and breast cancer screening showed relative decreases of 7.9% (P <.001), 5.9% (P = .01), and 4.6% (P <.001), respectively, with increasing panel size (from 1,200 to 3,900). Eight chronic care indicators (4 medication-based and 4 screening-based) showed no significant association with panel size. The likelihood of individuals with a new diagnosis of congestive heart failure having an echocardiogram, however, increased by a relative 8.1% (P <.001) with higher panel size. Increasing panel size was also associated with a 10.8% relative increase in hospitalization rates for ambulatory-care-sensitive conditions (P = .04) and a 10.8% decrease in non-urgent emergency department visits (P = .004). Continuity was highest with medium panel sizes (P <.001), and comprehensiveness had a small decrease (P = .03) with increasing panel size.

CONCLUSIONS

Increasing panel size was associated with small decreases in cancer screening, continuity, and comprehensiveness, but showed no consistent relationships with chronic disease management or access indicators. We found no panel size threshold above which quality of care suffered.

Trends in violence in England and Wales 2010-2014

BACKGROUND

The National Violence Surveillance Network (NVSN) of emergency departments (ED), minor injuries units and walk-in-centres in England and Wales has brought clarity to contradictory violence trends derived from crime survey and police data. Gender, age-specific and regional trends in violence-related injury in England and Wales since 2010 have not been studied.

METHODS

Data on violence-related injury were collected from a structured sample of 151 EDs in England and Wales. ED attendance date and age and gender of patients who reported injury in violence from 1 January 2010 to 31 December 2014 were identified from attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends.

RESULTS

In total, 247 016 (178 709 males: 72.3%) violence-related attendances were identified. Estimated annual injury rate across England and Wales was 4.4/1000 population (95% CI 3.9 to 4.9); males 6.5/1000 (95% CI 5.6 to 7.2) and females 2.4/1000 (95% CI 2.1 to 2.6). On average, overall attendances decreased by 13.8% per year over the 5 years (95% CI -14.8 to -12.1). Attendances decreased significantly for both genders and all age groups (0-10, 11-17, 18-30, 31-50, 51+ years); declines were greatest among children and adolescents. Significant decreases in violence-related injury were found in all but two regions. Violence peaked in May and July.

CONCLUSIONS

From an ED perspective, violence in England and Wales decreased substantially between 2010 and 2014, especially among children and adolescents. Violence prevention efforts should focus on regions with the highest injury rates and during the period May-July.

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data

Background

The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes.

Objective

To determine whether primary care access is associated with the route of emergency admission—via a GP versus via an A and E department.

Methods

Retrospective analysis of national administrative data from English hospitals for 2011–2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access—the percentage of patients able to get a general practice appointment on their last attempt—was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics.

Results

The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England.

Conclusions

Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear.

Association between general practice characteristics and use of out-of-hours GP cooperatives

Background

The use of out-of-hours healthcare services for non-urgent health problems is believed to be related to the organisation of daytime primary care but insight into underlying mechanisms is limited. Our objective was to examine the association between daytime general practice characteristics and the use of out-of-hours care GP cooperatives.

Methods

A cross-sectional observational study in 100 general practices in the Netherlands, connected to five GP cooperatives. In each GP cooperative, we took a purposeful sample of the 10 general practices with the highest use of out-of-hours care and the 10 practices with the lowest use.

Practice and population characteristics were obtained by questionnaires, interviews, data extraction from patient registration systems and telephone accessibility measurements. To examine which aspects of practice organisation were associated with patients’ use of out-of-hours care, we performed logistic regression analyses (low versus high out-of-hours care use), correcting for population characteristics.

Results

The mean out-of-hours care use in the high use group of general practices was 1.8 times higher than in the low use group. Day time primary care practices with more young children and foreigners in their patient populations and with a shorter distance to the GP cooperative had higher out-of-hours primary care use. In addition, longer telephone waiting times and lower personal availability for palliative patients in daily practice were associated with higher use of out-of-hours care. Moreover, out-of-hours care use was higher when practices performed more diagnostic tests and therapeutic procedures and had more assistant employment hours per 1000 patients.

Several other aspects of practice management showed some non-significant trends: high utilising general practices tended to have longer waiting times for non-urgent appointments, lower availability of a telephone consulting hour, lower availability for consultations after 5 p.m., and less frequent holiday openings.

Conclusions

Besides patient population characteristics, organisational characteristics of general practices are associated with lower use of out-of-hours care. Improving accessibility and availability of day time primary day care might be a potential effective way to improve the efficient use of out-of-hours care services.

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

Background

Recent increases in emergency admission rates have caused concern. Some emergency admissions may be avoidable if services in the emergency and urgent care system are available and accessible. A set of 14 conditions, likely to be rich in avoidable emergency admissions, was identified by expert consensus.

Objective

We aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.

Methods

The design was a sequential mixed-methods study in three phases. In phase 1 we calculated an age- and sex-adjusted avoidable admission rate for 2008–11. We located routine data on characteristics of emergency and urgent care systems and used linear regression to explain variation in avoidable admissions rates in 150 systems. In phase 2 we undertook in-depth case studies in six systems to identify further factors. A key part of these case studies was interviews with commissioners, service providers and patient representatives, totalling 82 interviews. In phase 3 we returned to the linear regression to test further factors identified in the case studies.

Results

The 14 conditions accounted for 3,273,395 admissions in 2008–11 (22% of all emergency admissions). The mean age- and sex-adjusted admission rate was 2258 per year per 100,000 population, with a 3.4-fold variation between systems (1268–4359). Characteristics of the population explained the majority of variation: deprivation explained 72% of variation, with urban/rural status explaining 3% more. Systems serving populations with high levels of deprivation and in urban areas had high rates of potentially avoidable admissions. Interviewees described the complexity of deprivation, representing high levels of morbidity, low awareness of alternative services to emergency departments and high expressed need for immediate access to urgent care. Factors related to emergency departments (EDs), hospitals, emergency ambulance services and general practice explained a further 10% of variation in avoidable admissions. Systems with high, potentially avoidable, admission rates had high rates of acute beds (suggesting supply-induced demand), high rates of attendance at EDs (which have been associated with poor perceived access to general practice), high rates of conversion from ED attendances to admissions, and low rates of non-transport to emergency departments by emergency ambulances. The six case studies revealed further possible explanations of variation: there was variation in how hospitals coded admissions; some systems focused proactively on admission avoidance whereas others were more interested in hospital discharge, for example use of multidisciplinary teams based at acute trusts; there were different levels of integration between different services such as health and social care, and acute and community trusts; and some systems faced more challenging problems around geographical boundaries operating for different services in the system. Interviewees often described admission as the easy or safe option.

Conclusions

Deprivation explained most of the variation in avoidable admission rates. Research is needed to understand the complex relationship between deprivation and avoidable admission, and to develop interventions tailored to avoid admissions from deprived communities. Standardisation of coding of admissions would reduce variation.

Funding

The National Institute for Health Research Health Service and Research Delivery programme.

Responsiveness of primary care services: development of a patient-report measure – qualitative study and initial quantitative pilot testing

Background

Primary care service providers do not always respond to the needs of diverse groups of patients, and so certain patients groups are disadvantaged. General practitioner (GP) practices are increasingly encouraged to be more responsive to patients’ needs in order to address inequalities.

Objectives

(1) Explore the meaning of responsiveness in primary care. (2) Develop a patient-report questionnaire for use as a measure of patient experience of responsiveness by a range of primary care organisations (PCOs). (3) Investigate methods of population mapping available to GP practices.

Design setting

PCOs, including GP practices, walk-in centres and community pharmacies.

Participants

Patients and staff from 12 PCOs in the East Midlands in the development stage, and 15 PCOs across three different regions of England in stage 3.

Interventions

To investigate what responsiveness means, we conducted a literature review and interviews with patients and staff in 12 PCOs. We developed, tested and piloted the use of a questionnaire. We explored approaches for GP practices to understand the diversity of their populations.

Main outcome measures

(1) Definition of primary care responsiveness. (2) Three patient-report questionnaires to provide an assessment of patient experience of GP, pharmacy and walk-in centre responsiveness. (3) Insight into challenges in collecting diversity data in primary care.

Results

The literature covers three overlapping themes of service quality, inequalities and patient involvement. We suggest that responsiveness is achieved through alignment between service delivery and patient needs, involving strategies to improve responsive service delivery, and efforts to manage patient expectations. We identified three components of responsive service delivery: proactive population orientation, reactive population orientation and individual patient orientation. PCOs tend to utilise reactive strategies rather than proactive approaches. Questionnaire development involved efforts to include patients who are ‘seldom heard’. The questionnaire was checked for validity and consistency and is available in three versions (GP, pharmacy, and walk-in centre), and in Easy Read format. We found the questionnaires to be acceptable to patients, and to have content validity. We produced some preliminary evidence of reliability and construct validity. Measuring and improving responsiveness requires PCOs to understand the characteristics of their patient population, but we identified significant barriers and challenges to this.

Conclusions

Responsiveness is a complex concept. It involves alignment between service delivery and the needs of diverse patient groups. Reactive and proactive strategies at individual and population level are required, but PCOs mainly rely on reactive approaches. Being responsive means giving good care equally to all, and some groups may require extra support. What this extra support is will differ in different patient populations, and so knowledge of the practice population is essential. Practices need to be motivated to collect and use diversity data. Future work needed includes further evaluation of the patient-report questionnaires, including Easy Read versions, to provide further evidence of their quality and acceptability; research into how to facilitative the use of patient experience data in primary care; and implementation of strategies to improve responsiveness, and evaluation of effectiveness.

Funding

The National Institute for Health Research Service Delivery and Organisation programme.

Which features of primary care affect unscheduled secondary care use? A systematic review

OBJECTIVES

To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care.

SETTING

Observational studies at primary care practice level.

PARTICIPANTS

Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions.

RESULTS

48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed.

CONCLUSIONS

The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions.

Exploration of population and practice characteristics explaining differences between practices in the proportion of hospital admissions that are emergencies

Background

Emergency (unscheduled) and elective (scheduled) use of secondary care varies between practices. Past studies have described factors associated with the number of emergency admissions; however, high quality care of chronic conditions, which might include increased specialist referrals, could be followed by reduced unscheduled care. We sought to characterise practices according to the proportion of total hospital admissions that were emergency admissions, and identify predictors of this proportion.

Method

The study included 229 general practices in Leicestershire, Northamptonshire and Rutland, England. Publicly available data were obtained on scheduled and unscheduled secondary care usage, and on practice and patient characteristics: age; gender; list size; observed prevalence, expected prevalence and the prevalence gap of coronary heart disease, hypertension and stroke; deprivation; headcount number of GPs per 1000 patients; total and clinical quality and outcomes framework (QOF) scores; ethnicity; proportion of patients seen within two days by a GP; proportion able to see their preferred GP. Using the proportion of admissions that were emergency admissions, seven categories of practices were created, and a regression analysis was undertaken to identify predictors of the proportion.

Results

In univariate analysis, practices with higher proportions of admissions that were emergencies tended to have fewer older patients, higher proportions of male patients, fewer white patients, greater levels of deprivation, smaller list sizes, lower recorded prevalence of coronary heart disease and stroke, a bigger gap between the expected and recorded levels of stroke, and lower proportions of total and clinical QOF points achieved. In the multivariate regression, higher deprivation, fewer white patients, more male patients, lower recorded prevalence of hypertension, more outpatient appointments, and smaller practice list size were associated with higher proportions of total admissions being emergencies.

Conclusion

In monitoring use of secondary care services, the role of population characteristics in determining levels of use is important, but so too is the ability of practices to meet the demands for care that face them. The level of resources, and the way in which available resources are used, are likely to be key in determining whether a practice is able to meet the health care needs of its patients.

Do difficulties in accessing in-hours primary care predict higher use of out-of-hours GP services? Evidence from an English National Patient Survey

Introduction

It is believed that some patients are more likely to use out-of-hours primary care services because of difficulties in accessing in-hours care, but substantial evidence about any such association is missing.

Methods

We analysed data from 567 049 respondents to the 2011/2012 English General Practice Patient Survey who reported at least one in-hours primary care consultation in the preceding 6 months. Of those respondents, 7% also reported using out-of-hours primary care. We used logistic regression to explore associations between use of out-of-hours primary care and five measures of in-hours access (ease of getting through on the telephone, ability to see a preferred general practitioner, ability to get an urgent or routine appointment and convenience of opening hours). We illustrated the potential for reduction in use of out-of-hours primary care in a model where access to in-hours care was made optimal.

Results

Worse in-hours access was associated with greater use of out-of-hours primary care for each access factor. In multivariable analysis adjusting for access and patient characteristic variables, worse access was independently associated with increased out-of-hours use for all measures except ease of telephone access. Assuming these associations were causal, we estimated that an 11% relative reduction in use of out-of-hours primary care services in England could be achievable if access to in-hours care were optimal.

Conclusions

This secondary quantitative analysis provides evidence for an association between difficulty in accessing in-hours care and use of out-of-hours primary care services. The findings can motivate the development of interventions to improve in-hour access.

Trends in community violence in England and Wales 2005-2009

PURPOSE

Injury records from Emergency Departments (EDs) have been studied over the last decade as part of the work of the National Violence Surveillance Network (NVSN) and provide information about local, regional and national violence levels and trends in England and Wales. The purpose of the current study is to evaluate overall, gender, age-specific and regional trends in community violence in England and Wales from an ED perspective from January 2005 to December 2009.

METHODS

Violence-related injury data were collected prospectively in a stratified sample of 77 EDs (Types 1, 3 and 4) in the nine Government Office Regions in England and in Wales. All 77 EDs were recruited on the basis that they had implemented and continued to comply with the provisions of the 1998 Data Protection Act and Caldicott guidance. Attendance date, age and gender of patients who reported injury in violence were identified using assault-related attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends.

RESULTS

In total 221,673 (163,384 males: 74%) violence-related attendances were identified. Overall estimated annual injury rate was 6.5 per 1000 resident population (males 9.8 and females 3.4 per 1000). Violence affecting males and females decreased significantly in England and Wales over the 5-year period, with an overall estimated annual decrease of 3% (95% CI: 1.8-4.1%, p<0.05). Attendances decreased significantly for both genders across four out of the five age groups studied. Attendances were found to be highest during the months of May and July and lowest in February. Substantial differences in violence-related ED attendances were identified at the regional level.

CONCLUSIONS

From this ED perspective overall violence in England and Wales decreased over the period 2005-2009 but increased in East Midlands, London and South West regions. Since 2006, overall trends according to Crime Survey for England and Wales (CSEW), police and ED measures were similar, though CSEW and ED measures reflect far greater numbers of violent incidents than police data. Causes of decreases in violence in regions need to be identified and shared with regions where violence increased.

Unscheduled return visits (URV) in adults to the emergency department (ED): a rapid evidence assessment policy review

Unscheduled return visits (URV) to the emergency department (ED) may be an important quality indicator of performance of individual clinicians as well as organisations and systems responsible for the delivery of emergency care. The aim of this study was to perform a rapid evidence assessment policy-based literature review of studies that have looked at URVs presenting to the ED. A rapid evidence assessment using SCOPUS and PUBMED was used to identify articles looking at unplanned returns to EDs in adults; those relating to specific complaints or frequent attenders were not included. After exclusions, we identified 26 articles. We found a reported URV rate of between 0.4% and 43.9% with wide variation in the time period defined for a URV, which ranged from 24 h to undefined. Thematic analysis identified four broad subtypes of URVs: related to patient factors, to the illness, to the system or organisation and to the clinician. This review informed the development of national clinical quality indicators for England. URV rates may serve as an important indicator of quality performance within the ED. However, review of the literature shows major inconsistencies in the way URVs are defined and measured. Furthermore, the review has highlighted that there are potentially at least four subcategories of URVs (patient related, illness related, system related and clinician related). Further work is in progress to develop standardised definitions and methodologies that will allow comparable research and allow URVs to be used reliably as a quality indicator for the ED.

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study

Background

Some emergency admissions can be avoided if acute exacerbations of health problems are managed by the range of health services providing emergency and urgent care.

Aim

To identify system-wide factors explaining variation in age sex adjusted admission rates for conditions rich in avoidable admissions.

Design

National ecological study.

Setting

152 emergency and urgent care systems in England.

Methods

Hospital Episode Statistics data on emergency admissions were used to calculate an age sex adjusted admission rate for conditions rich in avoidable admissions for each emergency and urgent care system in England for 2008–2011.

Results

There were 3 273 395 relevant admissions in 2008–2011, accounting for 22% of all emergency admissions. The mean age sex adjusted admission rate was 2258 per year per 100 000 population, with a 3.4-fold variation between systems (1268 and 4359). Factors beyond the control of health services explained the majority of variation: unemployment rates explained 72%, with urban/rural status explaining further variation (R²=75%). Factors related to emergency departments, hospitals, emergency ambulance services and general practice explained further variation (R²=85%): the attendance rate at emergency departments, percentage of emergency department attendances converted to admissions, percentage of emergency admissions staying less than a day, percentage of emergency ambulance calls not transported to hospital and perceived access to general practice within 48 h.

Conclusions

Interventions to reduce avoidable admissions should be targeted at deprived communities. Better use of emergency departments, ambulance services and primary care could further reduce avoidable emergency admissions.

Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study

BACKGROUND

The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England.

METHODS

A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services. MAIN RESULT AND CONCLUSION: General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.

Chronic disease detection and access: does access improve detection, or does detection make access more difficult?

BACKGROUND

The recorded detection of chronic disease by practices is generally lower than the prevalence predicted by population surveys.

AIM

To determine whether patient-reported access to general practice predicts the recorded detection rates of chronic diseases in that setting.

DESIGN AND SETTING

A cross-sectional study involving 146 general practices in Leicestershire and Rutland, England.

METHOD

The numbers of patients recorded as having chronic disease (coronary heart disease, chronic obstructive pulmonary disease, hypertension, diabetes) were obtained from Quality and Outcomes Framework (QOF) practice disease registers for 2008-2009. Characteristics of practice populations (deprivation, age, sex, ethnicity, proportion reporting poor health, practice turnover, list size) and practice performance (achievement of QOF disease indicators, patient experience of being able to consult a doctor within 2 working days and book an appointment >2 days in advance) were included in regression models.

RESULTS

Patient characteristics (deprivation, age, poor health) and practice characteristics (list size, turnover, QOF achievement) were associated with recorded detection of more than one of the chronic diseases. Practices in which patients were more likely to report being able to book appointments had reduced recording rates of chronic disease. Being able to consult a doctor within 2 days was not associated with levels of recorded chronic disease.

CONCLUSION

Practices with high levels of deprivation and older patients have increased rates of recorded chronic disease. As the number of patients recorded with chronic disease increased, the capacity of practices to meet patients' requests for appointments in advance declined. The capacity of some practices to detect and manage chronic disease may need improving.

Characteristics of general practices associated with numbers of elective admissions

BACKGROUND

In England both emergency (unplanned) and non-emergency (elective) hospital admissions have been increasing. Some elective admissions are potentially avoidable.

AIM

to identify the characteristics of general practices and patients associated with elective admissions.

METHODS

A cross-sectional study, in Leicestershire, England, was conducted using admission data (2006-07 and 2007-08). Practice characteristics (list size, distance from principal hospital, quality and outcomes framework score and general practitioner (GP) patient access survey data) and patient characteristics (age, ethnicity and deprivation and gender) were used as predictors of elective hospital admissions in a negative binomial regression model.

RESULTS

Practices with a higher proportion of patients aged 65 years or greater and of white ethnicity had higher rates of elective hospital admissions. Practices with more male patients and with more patients reporting being able to consult a particular GP had fewer elective hospital admissions. For 2007-08 practices with a larger list size were associated with higher elective hospital admissions. Quality and outcomes framework performance did not predict admission numbers.

CONCLUSIONS

As for unplanned admissions, elective admissions increase as being able to consult a particular GP declines. Interventions to improve continuity should be investigated. Practices face major problems in managing the increased need for planned care as the population ages.