Variation in referral rates to emergency departments and inpatient services from a GP out of hours service and the potential impact of alternative staffing models

Reasons for encounters, diagnoses, and admission rate among emergency referrals at an urban primary care clinic in Japan: A retrospective cohort study

Background

Comprehensive understanding of emergency referrals (EmR), encompassing reasons for encounters (RFEs) and diagnoses, is crucial for primary care physicians (PCPs). Comparing EmR rates and subsequent admission rates can potentially enhance the quality of primary care for EmR practice. However, no study has evaluated RFEs among patients with EmRs. This study aimed to identify RFE/diagnosis in relation to subsequent admission among patients receiving EmR.

Methods

We conducted a retrospective cohort study at an urban family physician teaching clinic in Kawasaki City, Japan. Our cohort recruited consecutive EmR episodes with their medical records and admissions confirmed through response letters from receiving hospitals. Using the 2nd edition of the International Classification of Primary Care, we explored the frequency of RFEs and diagnoses, calculating EmR rates and admission rates as primary outcomes. Bivariate analyses were employed to compare admission and non-admission cases.

Results

The present study encompassed 162 EmR episodes out of 47,901 visits, yielding an EmR rate of 3.38/1000 visits. Among 153 completely followed episodes, 99 patients were emergently admitted, resulting in a 64.7% admission rate. The admission group exhibited significantly higher age and a greater prevalence of dementia. Descriptive analysis revealed fever and pneumonia as the most frequent RFE and diagnosis, respectively, with significant differences between admission and non-admission groups.

Conclusions

The present study reports EmR and admission rates following EmR, highlighting differences in patient characteristics, RFEs, and diagnoses. The findings offer insights to enhance PCPs' EmR practices and serve as a benchmark for the scope of EmR practice.

Comparing the clinical practice and prescribing safety of locum and permanent doctors: observational study of primary care consultations in England

BACKGROUND

Temporary doctors, known as locums, are a key component of the medical workforce in the NHS but evidence on differences in quality and safety between locum and permanent doctors is limited. We aimed to examine differences in the clinical practice, and prescribing safety for locum and permanent doctors working in primary care in England.

METHODS

We accessed electronic health care records (EHRs) for 3.5 million patients from the CPRD GOLD database with linkage to Hospital Episode Statistics from 1st April 2010 to 31st March 2022. We used multi-level mixed effects logistic regression to compare consultations with locum and permanent GPs for several patient outcomes including general practice revisits; prescribing of antibiotics; strong opioids; hypnotics; A&E visits; emergency hospital admissions; admissions for ambulatory care sensitive conditions; test ordering; referrals; and prescribing safety indicators while controlling for patient and practice characteristics.

RESULTS

Consultations with locum GPs were 22% more likely to involve a prescription for an antibiotic (OR = 1.22 (1.21 to 1.22)), 8% more likely to involve a prescription for a strong opioid (OR = 1.08 (1.06 to 1.09)), 4% more likely to be followed by an A&E visit on the same day (OR = 1.04 (1.01 to 1.08)) and 5% more likely to be followed by an A&E visit within 1 to 7 days (OR = 1.05 (1.02 to 1.08)). Consultations with a locum were 12% less likely to lead to a practice revisit within 7 days (OR = 0.88 (0.87 to 0.88)), 4% less likely to involve a prescription for a hypnotic (OR = 0.96 (0.94 to 0.98)), 15% less likely to involve a referral (OR = 0.85 (0.84 to 0.86)) and 19% less likely to involve a test (OR = 0.81 (0.80 to 0.82)). We found no evidence that emergency admissions, ACSC admissions and eight out of the eleven prescribing safety indicators were different if patients were seen by a locum or a permanent GP.

CONCLUSIONS

Despite existing concerns, the clinical practice and performance of locum GPs did not appear to be systematically different from that of permanent GPs. The practice and performance of both locum and permanent GPs is likely shaped by the organisational setting and systems within which they work.

The impact of variation in out-of-hours doctors' referral practices: a Norwegian registry-based observational study

BACKGROUND

In a gatekeeping system, the individual doctor's referral practice is an important factor for hospital activity and patient safety.

OBJECTIVE

The aim of the study was to investigate the variation in out-of-hours (OOH) doctors' referral practice, and to explore these variations' impact on admissions for selected diagnoses reflecting severity, and 30-day mortality.

METHODS

National data from the doctors' claims database were linked with hospital data in the Norwegian Patient Registry. Based on the doctor's individual referral rate adjusted for local organizational factors, the doctors were sorted into quartiles of low-, medium-low-, medium-high-, and high-referral practice. The relative risk (RR) for all referrals and for selected discharge diagnoses was calculated using generalized linear models.

RESULTS

The OOH doctors' mean referral rate was 110 referrals per 1,000 consultations. Patients seeing a doctor in the highest referring practice quartile had higher likelihood of being referred to hospital and diagnosed with the symptom of pain in throat and chest, abdominal pain, and dizziness compared with the medium-low quartile (RR 1.63, 1.49, and 1.95). For the critical conditions of acute myocardial infarction, acute appendicitis, pulmonary embolism, and stroke, we found a similar, but weaker, association (RR 1.38, 1.32, 1.24, and 1.19). The 30-day mortality among patients not referred did not differ between the quartiles.

CONCLUSIONS

Doctors with high-referral practice referred more patients who were later discharged with all types of diagnoses, including serious and critical conditions. With low-referral practice, severe conditions might have been overlooked, although the 30-day mortality was not affected.

Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study

OBJECTIVES

To estimate the impact of altering referral thresholds from out-of-hours services on older patients' further use of health services and risk of death.

DESIGN

Cohort study using patient data from primary and specialised health services and demographic data from Statistics Norway and the Norwegian Cause of Death Registry.

SETTING

Norway PARTICIPANTS: 491 653 patients aged 65 years and older contacting Norwegian out-of-hours services between 2008 and 2016.

ANALYSIS

Multivariable adjusted and instrumental variable associations between referrals to hospital from out-of-hours services and further health services use and death for up to 6 months.Physicians' proportions of acute referrals of older, unknown patients from out-of-hours work were used as an instrumental variable ('physician referral preference') for their threshold of referral for such patients whose clinical presentations were less clear cut.

RESULTS

For older patients, whose referrals could be attributed to their physicians' threshold for referral, mean length of stay in hospital increased 3.30 days (95% CI 3.13 to 3.27) within the first 10 days, compared with non-referred patients. Such referrals also increased 6 months use of outpatient specialist clinics and primary care physicians. Importantly, patients with referrals attributable to their physicians' threshold had a substantially reduced risk of death the first 10 days (HR 0.53, 95% CI 0.31 to 0.91), an effect sustaining through the 6-month follow-up period (HR 0.72, 95% CI 0.54 to 0.97).

CONCLUSIONS

Out-of-hours patients whose referrals are affected by physician referral threshold contribute substantially to the use of health services. However, the referral seems protective by reducing the risk of death in the first 6 months after the referral. Thus, raising the threshold for referral to lower pressure on overcrowded emergency departments and hospitals should not be encouraged without ensuring the accuracy of the referral decisions, ideally through high-quality randomised controlled trial evidence.

Variation in general practice referral rate to acute medicine services and association with hospital admission. A retrospective observational study

BACKGROUND

Variation in general practice (GP) referral rates to outpatient services is well described however variance in rates of referral to acute medical units is lacking.

OBJECTIVE

To investigate variance in GP referral rate for acute medical assessment and subsequent need for hospital admission.

METHODS

A retrospective cohort study of acute medical referrals from 88 GPs in Lothian, Scotland between 2017 and 2020 was performed using practice population size, age, deprivation, care home residence, and distance from hospital as explanatory variables. Patient-level analysis of demography, deprivation, comorbidity, and acuity markers was subsequently performed on referred and clinically assessed acute medical patients (n = 42,424) to examine how practice referral behaviour reflects clinical need for inpatient hospital care.

RESULTS

Variance in GP referral rates for acute medical assessment was high (2.53-fold variation 1st vs. 4th quartile) and incompletely explained by increasing age and deprivation (adjusted R2 0.67, P < 0.001) such that significant variance remained after correction for confounders (2.15-fold). Patients from the highest referring quartile were significantly less likely to require hospital admission than those from the third, second, or lowest referring quartiles (adjusted odds ratio 1.28 [1.21-1.36, P < 0.001]; 1.30 [1.23-1.37, P < 0.001]; 1.53 [1.42-1.65, P < 0.001]).

CONCLUSIONS

High variation in GP practice referral rate for acute medical assessment is incompletely explained by practice population socioeconomic factors and negatively associates with need for urgent inpatient care. Identifying modifiable factors influencing referral rate may provide opportunities to facilitate community-based care and reduce congestion on acute unscheduled care pathways.

Characteristics of Patients Who Visited Emergency Department: A Nationwide Population-Based Study in South Korea (2016-2018)

The utilization of the emergency department (ED) has been continuously increasing and has become a burden for ED resources. The aim of this study was to describe the characteristics, outcomes, common diagnoses, and disease classifications of patients who were referred to the ED. This nationwide epidemiologic study examined the data from adult patients (>18 years) who visited EDs from 1 January 2016 to 31 December 2018. Most EDs in Korea provide data from ED patients to the National Emergency Medical Center (NEMC). The disposition of ED patients was classified as discharge, admission, death, and re-transfer. From 2016 to 2018, the proportion of referred patients out of the total ED visits increased from 7.3% to 7.8%. The referred patients were older (61.1 vs. 50.5 years), had worse vital signs, longer ED lengths of stay (409.1 vs. 153.3 min), and higher admission (62.3 vs. 16.9%) and re-transfer rates (4.4 vs. 1.9%) than the direct-visit patients. Among the referred patients in the 3 years, 62.3% were hospitalized, and the most common disease classification was “disease of the digestive system” (19.8%). The most common diagnosis was pneumonia (6.0%), followed by urinary tract infection, gastrointestinal bleeding, and hepatobiliary infection. The number of patients referred to EDs is increasing, and more than 60% of referred patients are hospitalized. Detailed characteristics of these patients will be helpful for improving ED management and the distribution of medical resources.

Reasons for acute referrals to hospital from general practitioners and out-of-hours doctors in Norway: a registry-based observational study

Background

General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral.

Methods

A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR.

Results

Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men.

Conclusions

The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.

Triaging and referring in adjacent general and emergency departments (the TRIAGE trial): A cluster randomised controlled trial

OBJECTIVES

To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC).

METHODS

Unblinded randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard).

RESULTS

In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised.

CONCLUSIONS

ED nurses using a new tool safely diverted 9.5% of the included patients to primary care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03793972.