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Laudicella M, Li Donni P, Prete V. Healthcare utilisation by diabetic patients in Denmark: the role of primary care in reducing emergency visits. Health Policy 2024; 145:105079. [PMID: 38772252 DOI: 10.1016/j.healthpol.2024.105079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/23/2023] [Accepted: 05/03/2024] [Indexed: 05/23/2024]
Abstract
Improving the management of diabetic patients is receiving increasing attention in the health policy agenda due to increasing prevalence in the population and raising pressure on healthcare resources. This paper examines the determinants of healthcare services utilisation in patients with type-2 diabetes, investigating the potential substitution effect of general practice visits on the utilisation of emergency department visits. By using rich longitudinal data from Denmark and a bivariate econometric model, our analysis highlights primary care services that are more effective in preventing emergency department visits and socioeconomic groups of patients with a weak substitution response. Our results suggest that empowering primary care services, such as preventive assessment visits, may contribute to reducing emergency department visits significantly. Moreover, special attention should be devoted to vulnerable groups, such as patients from low socioeconomic background and older patients, who may find more difficult achieving a large substitution response.
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Affiliation(s)
- Mauro Laudicella
- Department of Economic Analysis, Universidad Autonoma de Madrid (UAM), Madrid, Spain; Danish Center for Health Economics (DaCHE), University of Southern Denmark, Odense, Denmark.
| | - Paolo Li Donni
- Danish Center for Health Economics (DaCHE), University of Southern Denmark, Odense, Denmark; University of Palermo, Department of Economics, Business and Statistics, Palermo, Italy.
| | - Vincenzo Prete
- University of Palermo, Department of Law, Palermo, Italy.
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Kümpel C, Schneider U. Additional reimbursement for outpatient physicians treating nursing home residents reduces avoidable hospital admissions: Results of a reimbursement change in Germany. Health Policy 2020; 124:470-477. [PMID: 32145922 DOI: 10.1016/j.healthpol.2020.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 01/18/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
Potentially avoidable hospitalizations of nursing home residents are costly and may even be harmful for the residents concerned. This study analyzes whether the introduction, in Germany in 2016, of an additional reimbursement for outpatient care physicians treating nursing home residents has led to a reduction in hospital admissions. This analysis exploits the introduction of the additional reimbursement in a difference-in-difference approach, using recipients of professional home care as a control. The analysis is based on claims data from the largest German sickness fund, which provide complete information on health care and long-term care utilization for each insured person. Our analysis highlights a 5-percent reduction in overall hospital stays and an 8-percent reduction in ambulatory care-sensitive admissions as a result of the additional reimbursements. However, we found no effect for short-term hospital admissions or for admissions at night or at the weekend. We conclude that the overall health care utilization for nursing home patients seems to have improved due to an increased presence of physicians in nursing homes during daytime working hours. Thus, an additional reimbursement for outpatient care physicians seems to be an effective tool to reduce potentially avoidable hospital admissions in the nursing home sector. However, it does not appear to improve emergency care utilization, especially out-of-hour.
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Affiliation(s)
- Christian Kümpel
- Hamburg Center for Health Economics, Esplanade 36, D-20354 Hamburg, Germany.
| | - Udo Schneider
- Techniker Krankenkasse, Bramfelder Straße 140, D-22305 Hamburg, Germany.
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Kümpel C. Do financial incentives influence the hospitalization rate of nursing home residents? Evidence from Germany. HEALTH ECONOMICS 2019; 28:1235-1247. [PMID: 31523874 DOI: 10.1002/hec.3930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 06/10/2023]
Abstract
Efficient health-care provision for nursing home residents is a concern in many OECD (Organization for Economic Cooperation and Development) countries. This paper analyzes whether nursing homes respond to financial incentives when deciding whether to hospitalize their residents. In Germany, reimbursements for nursing homes are reduced after a defined number of days when a resident stays in a hospital instead of a nursing home. As a result of a federal law introduced in 2008, some German states had to change the point at which reimbursements to nursing homes are reduced so that reductions are made from Day 4 instead of Day 1 of a resident's absence. This exogenously raised an incentive for the nursing homes affected to hospitalize residents especially for an expected short-term stay. This analysis exploits the introduction of the law in a difference-in-difference approach, using market-wide German-DRG files covering all hospital patients discharged from hospitals to nursing homes from 2007 to 2011. The results suggest an increase of approximately 11% in short-term hospital stays as a consequence of the longer reimbursement period introduced by the law.
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Affiliation(s)
- Christian Kümpel
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
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Krämer J, Schreyögg J. Substituting emergency services: primary care vs. hospital care. Health Policy 2019; 123:1053-1060. [PMID: 31500837 DOI: 10.1016/j.healthpol.2019.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 05/30/2019] [Accepted: 08/16/2019] [Indexed: 11/29/2022]
Abstract
Overcrowding in emergency departments (EDs) is inefficient, especially if it is caused by inappropriate visits for which primary care physicians could be equally effective as a hospital ED. Our paper investigates the extent to which both ambulatory ED visits and inpatient ED admissions are substitutes for primary care emergency services (PCES) in Germany. We use extensive longitudinal data and fixed effects models. Moreover, we add interaction terms to investigate the influence of various determinants on the strength of the substitution. Our results show significant substitution between PCES and ambulatory ED visits. Regarding the determinants, we find the largest substitution for younger patients. The more accessible the hospital ED is, the significantly larger the substitution. Moreover, substitution is larger among better-educated patients. For inpatient ED admission, we find significant substitution that is eight times smaller than the substitution for ambulatory ED visits. With regard to the determinants, we find the strongest substitution for non-urgent, short-stay admission and elderly patients. Countries with no gate-keeping system (such as Germany) have difficulties redirecting the patients streaming to EDs. Our estimated elasticities can help policy makers to resolve this issue, as our findings indicate where incentivizing the utilization of PCES is particularly effective.
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Affiliation(s)
- Jonas Krämer
- Hamburg Centre for Health Economics, Universität Hamburg, 20354 Hamburg, Germany.
| | - Jonas Schreyögg
- Hamburg Centre for Health Economics, Universität Hamburg, 20354 Hamburg, Germany.
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Seo DH, Kim MJ, Kim KH, Park J, Shin DW, Kim H, Jeon W, Kim H, Park JM. The characteristics of pediatric emergency department visits in Korea: An observational study analyzing Korea Health Panel data. PLoS One 2018; 13:e0197929. [PMID: 29795653 PMCID: PMC5967710 DOI: 10.1371/journal.pone.0197929] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/10/2018] [Indexed: 11/19/2022] Open
Abstract
Objective We investigated the characteristics of pediatric emergency department (ED) patients in Korea and determined factors associated with hospital admission after ED treatment. Methods Korea Health Panel data from 2008 through 2013 were analyzed retrospectively; we included patients under 18 years old who visited the ED at least once. We collected patient and household epidemiologic data such as sex, age group, region of residence, disability, chronic disease, household income quintile, national health insurance type, use of private insurance, and annual frequency of ED visits. We also examined data related to each ED visit, such as reason for visit, medical service provided, and hospital size/ownership. We then investigated which factors were correlated with case disposition (discharge home or hospital admission) after ED treatment. Results In total, 3,160 pediatric ED visits occurred during the six-year period. Males (57.5%) and children aged 0–5 years (47.7%) made more visits than females and older children, respectively. The proportion of ED visits for disease (67.7%) was much higher than for injury or poisoning (32.2%), and 452 cases (14.3%) required hospital admission. For hospital admission, the odds ratio (OR) of females was 0.73 compared to males, and the OR of children aged 6–11 was 0.68 compared to children aged 0–5. The OR of capital residents was 0.69 compared to province residents, and the OR of the highest income quintile was 0.51 compared to the lowest quintile. The OR of children with private insurance coverage was 0.49 compared to those lacking private insurance, and the OR of ED visits due to disease was 1.82 compared to visits due to injury/poisoning. Conclusion This analysis of clinical and demographic characteristics of pediatric ED visits and hospital admissions can serve as the foundation of future prospective studies required for establishing appropriate policies for the Korean pediatric emergency medical system.
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Affiliation(s)
- Dong Hyun Seo
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Kim
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Junseok Park
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Dong Wun Shin
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hoon Kim
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Woochan Jeon
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hyunjong Kim
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Joon Min Park
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
- * E-mail:
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Karam M, Tricas-Sauras S, Darras E, Macq J. Interprofessional Collaboration between General Physicians and Emergency Department Teams in Belgium: A Qualitative Study. Int J Integr Care 2017; 17:9. [PMID: 29588632 PMCID: PMC5853879 DOI: 10.5334/ijic.2520] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 08/23/2017] [Indexed: 11/28/2022] Open
Abstract
This study aimed to assess interprofessional collaboration between general physicians and emergency departments in the French speaking regions of Belgium. Eight group interviews were conducted both in rural and urban areas, including in Brussels. Findings showed that the relational components of collaboration, which are highly valued by individuals involved, comprise mutual acquaintanceship and trust, shared power and objectives. The organizational components of collaboration included out-of-hours services, role clarification, leadership and overall environment. Communication and patient's role were also found to be key elements in enhancing or hindering collaboration across these two levels of care. Relationships between general physicians and emergency departments' teams were tightly linked to organizational factors and the general macro-environment. Health system regulation did not appear to play a significant role in promoting collaboration between actors. A better role clarification is needed in order to foster multidisciplinary team coordination for a more efficient patient management. Finally, economic power and private practice impeded interprofessional collaboration between the care teams. In conclusion, many challenges need to be addressed for achievement of a better collaboration and more efficient integration. Not only should integration policies aim at reinforcing the role of general physicians as gatekeepers, also they should target patients' awareness and empowerment.
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Ifediora CO, Rogers GD. Patient-reported impact of after-hours house-call services on the utilization of emergency department services in Australia. Fam Pract 2017; 34:593-598. [PMID: 28472461 DOI: 10.1093/fampra/cmx038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This paper explores, from the patients' perspective, the likely impact of the Australian after-hours house-call (AHHC) medical services on emergency department (ED) presentations. This has become imperative given the significant cost difference between patient presentations to either the AHHC or ED and their practical implications for health care funding. DESIGN, SETTING AND PARTICIPANTS A cross-sectional, self-reported survey of all 10 838 patients in Australia known to have patronized AHHC services over the last week of January 2016. MAIN OUTCOME MEASURE The study used a validated, self-completion questionnaire, dispatched through a mixture of online and postal methods. RESULTS A total of 1228 questionnaires were returned, of which 1211 included all relevant sections of the survey (11.2% response rate). Four hundred and eighty-six patients (40.1%) indicated that they would have gone to the ED on the same day or night of their illness had the AHHC not been available, with the elderly (≥65) and children (<16) accounting for nearly two-thirds of these (64.6%). Following their AHHC consultations, 103 (8.5%) patients eventually attended the ED, meaning that the service prevented 383 patients from attending the ED, a decrease of 78.8%. Stratification based on location showed that this impact was seen across all states and territories in Australia where AHHC services exist, ranging from a reduction of 73.9% in Western Australia to 85.0% in Tasmania. Similarly, the impact cuts across all patient demographics, including age ranges, gender and social divides. CONCLUSIONS Based on our respondents' reports, AHHC services appear to be associated with a reduction in ED visits in Australia, with the impact cutting across all regions and patient demographics.
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Affiliation(s)
- Chris O Ifediora
- School of Medicine, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Gary D Rogers
- School of Medicine, Griffith University, Gold Coast Campus, Queensland, Australia
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Tammes P, Morris RW, Brangan E, Checkland K, England H, Huntley A, Lasserson D, MacKichan F, Salisbury C, Wye L, Purdy S. 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. BMC Health Serv Res 2017; 17:546. [PMID: 28789652 PMCID: PMC5549356 DOI: 10.1186/s12913-017-2483-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Richard W Morris
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emer Brangan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Alyson Huntley
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel Lasserson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona MacKichan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lesley Wye
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Dolton P, Pathania V. Can increased primary care access reduce demand for emergency care? Evidence from England's 7-day GP opening. JOURNAL OF HEALTH ECONOMICS 2016; 49:193-208. [PMID: 27395472 DOI: 10.1016/j.jhealeco.2016.05.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 06/06/2023]
Abstract
Restricted access to primary care can lead to avoidable, excessive use of expensive emergency care. Since 2013, partly to alleviate overcrowding at the Accident & Emergency (A&E) units of hospitals, the UK has been piloting 7-day opening of General Practitioner (GP) practices to improve primary care access for patients. We evaluate the impact of these pilots on patient attendances at A&E. We estimate that 7-day GP opening has reduced A&E attendances by patients of pilot practices by 9.9% with most of the impact on weekends which see A&E attendances fall by 17.9%. The effect is non-monotonic in case severity with most of the fall occurring in cases of moderate severity. An additional finding is that there is also a 9.9% fall in weekend hospital admissions (from A&E) which is entirely driven by a fall in admissions of elderly patients. The impact on A&E attendances appears to be bigger among wealthier patients. We present evidence in support of a causal interpretation of our results and discuss policy implications.
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Affiliation(s)
- Peter Dolton
- Department of Economics, University of Sussex, United Kingdom; CEP, LSE, United Kingdom.
| | - Vikram Pathania
- Department of Economics, University of Sussex, United Kingdom.
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Ramlakhan S, Mason S, O'Keeffe C, Ramtahal A, Ablard S. Primary care services located with EDs: a review of effectiveness. Emerg Med J 2016; 33:495-503. [PMID: 27068868 DOI: 10.1136/emermed-2015-204900] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 12/26/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Primary care focused unscheduled care centres (UCC) co-located with major EDs have been proposed as a solution to the rise in ED attendances. They aim to reduce the burden of primary care patients attending the ED, hence reducing crowding, waits and cost.This review analysed available literature in the context of the impact of general practitioner (GP) delivered, hospital-based (adjacent or within the ED) unscheduled care services on process outcomes, cost-effectiveness and patient satisfaction. METHODS A narrative literature review of studies published between 1980 and 2015 was undertaken. All study types were reviewed and included if they reported a service model using hospital-based primary care clinicians with a control consisting of standard ED clinician-delivered care. RESULTS The electronic searches yielded 7544 citations, with 20 records used in the review. These were grouped into three main themes: process outcomes, cost-effectiveness and satisfaction. A paradoxical increase in attendances has been described, which is likely to be attributable to provider-induced demand, and the evidence for improved throughput is poor. Marginal savings may be realised per patient, but this is likely to be overshadowed by the overall cost of introducing a new service. CONCLUSIONS There is little evidence to support the implementation of co-located UCC models. A robust evaluation of proposed models is needed to inform future policy.
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Affiliation(s)
- Shammi Ramlakhan
- Sheffield Children's Hospital, Sheffield, UK School of Health & Related Research, University of Sheffield, Sheffield, UK Sheffield Teaching Hospitals, Sheffield, UK
| | - Suzanne Mason
- School of Health & Related Research, University of Sheffield, Sheffield, UK Sheffield Teaching Hospitals, Sheffield, UK
| | - Colin O'Keeffe
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | | | - Suzanne Ablard
- School of Health & Related Research, University of Sheffield, Sheffield, UK
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Neill SJ, Jones CHD, Lakhanpaul M, Roland DT, Thompson MJ. Parents' help-seeking behaviours during acute childhood illness at home: A contribution to explanatory theory. J Child Health Care 2016; 20:77-86. [PMID: 25296933 DOI: 10.1177/1367493514551309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Uncertainty and anxiety surround parents' decisions to seek medical help for an acutely ill child. Consultation rates for children are rising, yet little is known about factors that influence parents' help-seeking behaviours. We used focus groups and interviews to examine how 27 parents of children under five years, from a range of socioeconomic groups in the East Midlands of England, use information to make decisions during acute childhood illness at home. This article reports findings elucidating factors that influence help-seeking behaviours. Parents reported that decision-making during acute childhood illness was influenced by a range of personal, social and health service factors. Principal among these was parents' concern to do the right thing for their child. Their ability to assess the severity of the illness was influenced by knowledge and experience of childhood illness. When parents were unable to access their general practitioner (GP), feared criticism from or had lost trust in their GP, some parents reported using services elsewhere such as Accident and Emergency. These findings contribute to explanatory theory concerning parents' help-seeking behaviours. Professional and political solutions have not reduced demand; therefore, collaborative approaches involving the public and professionals are now needed to improve parents' access to information.
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Affiliation(s)
- Sarah J Neill
- School of Health, University of Northampton, Northampton, UK
| | - Caroline H D Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Monica Lakhanpaul
- General and Adolescent Paediatrics Unit, Institute of Child Health, University College London, London, UK
| | - Damian T Roland
- Paediatric Emergency Medicine Leicester Academic Group, Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Matthew J Thompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Neill S, Roland D, Jones CHD, Thompson M, Lakhanpaul M. Information resources to aid parental decision-making on when to seek medical care for their acutely sick child: a narrative systematic review. BMJ Open 2015; 5:e008280. [PMID: 26674495 PMCID: PMC4691730 DOI: 10.1136/bmjopen-2015-008280] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To identify the effectiveness of information resources to help parents decide when to seek medical care for an acutely sick child under 5 years of age, including the identification of factors influencing effectiveness, by systematically reviewing the literature. METHODS 5 databases and 5 websites were systematically searched using a combination of terms on children, parents, education, acute childhood illness. A narrative approach, assessing quality via the Mixed Methods Appraisal Tool, was used due to non-comparable research designs. RESULTS 22 studies met the inclusion criteria: 9 randomised control trials, 8 non-randomised intervention studies, 2 qualitative descriptive studies, 2 qualitative studies and 1 mixed method study. Consultation frequency (15 studies), knowledge (9 studies), anxiety/reassurance (7 studies), confidence (4 studies) satisfaction (4 studies) and antibiotic prescription (4 studies) were used as measures of effectiveness. Quality of the studies was variable but themes supported information needing to be relevant and comprehensive to enable parents to manage an episode of minor illness Interventions addressing a range of symptoms along with assessment and management of childhood illness, appeared to have the greatest impact on the reported measures. The majority of interventions had limited impact on consultation frequencies, No conclusive evidence can be drawn from studies measuring other outcomes. CONCLUSIONS Findings confirm that information needs to be relevant and comprehensive to enable parents to manage an episode of minor illness. Incomplete information leaves parents still needing to seek help and irrelevant information appears to reduce parents' trust in the intervention. Interventions are more likely to be effective if they are also delivered in non-stressful environments such as the home and are coproduced with parents.
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Affiliation(s)
- Sarah Neill
- School of Health, University of Northampton, Northampton, UK
| | - Damian Roland
- Sapphire Group, Health Sciences, University of Leicester, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospitals, Leicester, UK
| | - Caroline HD Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, USA
| | - Monica Lakhanpaul
- Department of Population, Policy and Practice, Institute of Child Health, University College London, London, UK
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Wilson A, Baker R, Bankart J, Banerjee J, Bhamra R, Conroy S, Kurtev S, Phelps K, Regen E, Rogers S, Waring J. Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline.ObjectivesTo identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations.DesignMixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’.ParticipantsSix study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed.ResultsBetween 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration.ConclusionsRising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system.Future workResearch on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments.Study registrationUK Clinical Reasearch Network 12960.Funding detailsThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - John Bankart
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ran Bhamra
- Wolfson School of Mechanical and Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - Simon Conroy
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Stoyan Kurtev
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Stephen Rogers
- Department of Public Health, NHS Northamptonshire, Northampton, UK
| | - Justin Waring
- Business School, University of Nottingham, Nottingham, UK
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14
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Engelbrecht A, du Toit FG, Geyser MM. A cross-sectional profile and outcome assessment of adult patients triaged away from Steve Biko Academic Hospital emergency unit. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2015.1024013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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15
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Blakeley C, Blakemore A, Hunter C, Guthrie E, Tomenson B, Dickens C. Does anxiety predict the use of urgent care by people with long term conditions? A systematic review with meta-analysis. J Psychosom Res 2014; 77:232-9. [PMID: 25149033 PMCID: PMC4153376 DOI: 10.1016/j.jpsychores.2014.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The role of anxiety in the use of urgent care in people with long term conditions is not fully understood. A systematic review was conducted with meta-analysis to examine the relationship between anxiety and future use of urgent healthcare among individuals with one of four long term conditions: diabetes; coronary heart disease, chronic obstructive pulmonary disease and asthma. METHODS Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane Library were conducted These searches were supplemented by hand-searching bibliographies, citation tracing eligible studies and asking experts within the field about relevant studies. Studies were eligible for inclusion if they: a) used a standardised measure of anxiety, b) used prospective cohort design, c) included adult patients diagnosed with coronary heart disease (CHD), asthma, diabetes or chronic obstructive pulmonary disease (COPD), d) assessed urgent healthcare use prospectively. Data regarding participants, methodology, and association between anxiety and urgent care use was extracted from studies eligible for inclusion. Odds ratios were calculated for each study and pooled using random effects models. RESULTS 8 independent studies were identified for inclusion in the meta-analysis, with a total of 28,823 individual patients. Pooled effects indicate that anxiety is not associated with an increase in the use of urgent care (OR=1.078, p=0.476), regardless of the type of service, or type of medical condition. CONCLUSIONS Anxiety is not associated with increased use of urgent care. This finding is in contrast to similar studies which have investigated the role of depression as a risk factor for use of urgent care.
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Affiliation(s)
- Claire Blakeley
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, UK.
| | - Amy Blakemore
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, UK; NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Sciences Centre, University of Manchester, Williamson Building, Oxford Road, M13 9WL, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Else Guthrie
- Department of Psychiatry, Manchester Mental Health and Social Care Trust, UK
| | - Barbara Tomenson
- Biostatistics Unit, Institute of Population Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK
| | - Chris Dickens
- Mental Health Research Group, University of Exeter Medical School, UK; National Institute for Health Research (NIHR), Collaboration for Leadership in Applied Health Research & Care (CLAHRC) for the South West Peninsula (PenCLAHRC), UK
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16
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Huntley A, Lasserson D, Wye L, Morris R, Checkland K, England H, Salisbury C, Purdy S. Which features of primary care affect unscheduled secondary care use? A systematic review. BMJ Open 2014; 4:e004746. [PMID: 24860000 PMCID: PMC4039790 DOI: 10.1136/bmjopen-2013-004746] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
- Alyson Huntley
- School of Community & Social Medicine, Centre of Academic Primary Care, University of Bristol, Bristol, UK
| | - Daniel Lasserson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lesley Wye
- School of Community & Social Medicine, Centre of Academic Primary Care, University of Bristol, Bristol, UK
| | - Richard Morris
- Primary Care & Population Health, Royal Free Campus, London, UK
| | - Kath Checkland
- Institute of Population Health, Centre for Primary Care, University of Manchester, Manchester, UK
| | - Helen England
- School of Community & Social Medicine, Centre of Academic Primary Care, University of Bristol, Bristol, UK
| | - Chris Salisbury
- School of Community & Social Medicine, Centre of Academic Primary Care, University of Bristol, Bristol, UK
| | - Sarah Purdy
- School of Community & Social Medicine, Centre of Academic Primary Care, University of Bristol, Bristol, UK
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Abstract
The combined pressures of the European Working Time Directive, 4 h waiting time target, and growing rates of unplanned hospital attendances have forced a major consolidation of eye casualty departments across the country, with the remaining units seeing a rapid increase in demand. We examine the effect of these changes on the provision of emergency eye care in Central London, and see what wider lessons can be learned. We surveyed the managers responsible for each of London's 8 out-of-hours eye casualty services, analysed data on attendance numbers, and conducted detailed interviews with lead clinicians. At London's two largest units, Moorfields Eye Hospital and the Western Eye Hospital, annual attendance numbers have been rising at 7.9% per year (to 76 034 patients in 2010/11) and 9.6% per year (to 31 128 patients in 2010/11), respectively. Using Moorfields as a case study, we discuss methods to increase capacity and efficiency in response to this demand, and also examine some of the unintended consequences of service consolidation including patients travelling long distances to geographically inappropriate units, and confusion over responsibility for out-of-hours inpatient cover. We describe a novel 'referral pathway' developed to minimise unnecessary travelling and delay for patients, and propose a forum for the strategic planning of London's eye casualty services in the future.
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Affiliation(s)
- H B Smith
- Eye Casualty Department, Moorfields Eye Hospital, London, UK.
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18
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Bardsley M, Blunt I, Davies S, Dixon J. Is secondary preventive care improving? Observational study of 10-year trends in emergency admissions for conditions amenable to ambulatory care. BMJ Open 2013; 3:bmjopen-2012-002007. [PMID: 23288268 PMCID: PMC3549201 DOI: 10.1136/bmjopen-2012-002007] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To identify trends in emergency admissions for patients with clinical conditions classed as 'ambulatory care sensitive' (ACS) and assess if reductions might be due to improvements in preventive care. DESIGN Observational study of routinely collected hospital admission data from March 2001 to April 2011. Admission rates were calculated at the population level using national population estimates for area of residence. PARTICIPANTS All emergency admissions to National Health Service (NHS) hospitals in England from April 2001 to March 2011 for people residents in England. MAIN OUTCOME MEASURES Age-standardised emergency admissions rates for each of 27 specific ACS conditions (ICD-10 codes recorded as primary or secondary diagnoses). RESULTS Between April 2001 and March 2011 the number of admissions for ACS conditions increased by 40%. When ACS conditions were defined solely on primary diagnosis, the increase was less at 35% and similar to the increase in emergency admissions for non-ACS conditions. Age-standardised rates of emergency admission for ACS conditions had increased by 25%, and there were notable variations by age group and by individual condition. Overall, the greatest increases were for urinary tract infection, pyelonephritis, pneumonia, gastroenteritis and chronic obstructive pulmonary disease. There were significant reductions in emergency admission rates for angina, perforated ulcers and pelvic inflammatory diseases but the scale of these successes was relatively small. CONCLUSIONS Increases in rates of emergency admissions suggest that efforts to improve the preventive management of certain clinical conditions have failed to reduce the demand for emergency care. Tackling the demand for hospital care needs more radical approaches than those adopted hitherto if reductions in emergency admission rates for ACS conditions overall are to be seen as a positive outcome of for NHS.
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Affiliation(s)
| | | | - Sian Davies
- Southwark Business Support Unit, NHS South East London, London,UK
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19
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Redmond P, Darker C, McDonnell M, O'Shea B. Establishing a general practitioner led minor injury service: mixed methods evaluation at 10 months with an emphasis on use of radiology by GPs in the out-of-hours setting. Ir J Med Sci 2012; 182:213-6. [PMID: 23115022 DOI: 10.1007/s11845-012-0860-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Accepted: 10/18/2012] [Indexed: 10/27/2022]
Abstract
AIMS AND METHODS A mixed methods study was conducted to evaluate a recently established general practitioner (GP) led minor injury (MI) service; it included a patient feedback study, a qualitative enquiry into the experience of the MI GPs, and analysis of use of radiology. RESULTS Forty-nine (81.6 %) patients surveyed were seen in 30 min or less. Forty-five (75 %) felt that the quality of the service was excellent/very good. Twenty-seven (45 %) responders felt that the X-ray service was expensive; 49 (81.6 %) patients said that they would be happy to use the service again. 271 X-rays were taken (137, 50.55 % upper limb, 95, 35.06 % lower limb, 18, 6.64 % CXR). One hundred and ninety-four (73.48 %) patients were self-financing. There was an 86.72 % (235/271) concordance between GP/radiologist findings. Issues elaborated by MI GPs at the focus group included secondary care/hospital interaction, patients' experience, professional fulfilment, competence concerns, finances, and interest in educational resources; they were unanimous in maintaining the service at 10 months. CONCLUSIONS This study demonstrates a positive experience by patients, and conservative evaluation of X-rays by GPs.
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Affiliation(s)
- P Redmond
- TCD/HSE General Practice Training Scheme, Department of Public Health and Primary Care, Trinity College Centre for Health Sciences, Tallaght Hospital, Tallaght, Dublin 24, Ireland.
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20
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Boyle A, Beniuk K, Higginson I, Atkinson P. Emergency department crowding: time for interventions and policy evaluations. Emerg Med Int 2012; 2012:838610. [PMID: 22454772 PMCID: PMC3290817 DOI: 10.1155/2012/838610] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 10/13/2011] [Indexed: 11/17/2022] Open
Abstract
This paper summarises the consequences of emergency department crowding. It provides a comparison of the scales used to measure emergency department crowding. We discuss the multiple causes of crowding and present an up-to-date literature review of the interventions that reduce the adverse consequences of crowding. We consider interventions at the level of an individual hospital and a policy level.
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Affiliation(s)
- Adrian Boyle
- Emergency Department, Cambridge University Foundation Hospitals NHS Trust, Hills Road, Cambridge CB2 2QQ, UK
| | - Kathleen Beniuk
- Engineering Design Centre, Cambridge University, Cambridge CB2 1PZ, UK
| | - Ian Higginson
- Emergency Department, Plymouth Hospitals NHS Trust, Derriford Road, Crownhill, Plymouth, Devon PL6 8DH, UK
| | - Paul Atkinson
- Emergency Department, St John Regional Hospital, New Brunswick, Canada
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21
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Blakey JD, Guy D, Simpson C, Fearn A, Cannaby S, Wilson P, Shaw D. Multimodal observational assessment of quality and productivity benefits from the implementation of wireless technology for out of hours working. BMJ Open 2012; 2:e000701. [PMID: 22466035 PMCID: PMC3317138 DOI: 10.1136/bmjopen-2011-000701] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The authors investigated if a wireless system of call handling and task management for out of hours care could replace a standard pager-based system and improve markers of efficiency, patient safety and staff satisfaction. DESIGN Prospective assessment using both quantitative and qualitative methods, including interviews with staff, a standard satisfaction questionnaire, independent observation, data extraction from work logs and incident reporting systems and analysis of hospital committee reports. SETTING A large teaching hospital in the UK. PARTICIPANTS Hospital at night co-ordinators, clinical support workers and junior doctors handling approximately 10 000 tasks requested out of hours per month. OUTCOME MEASURES Length of hospital stay, incidents reported, co-ordinator call logging activity, user satisfaction questionnaire, staff interviews. RESULTS Users were more satisfied with the new system (satisfaction score 62/90 vs 82/90, p=0.0080). With the new system over 70 h/week of co-ordinator time was released, and there were fewer untoward incidents related to handover and medical response (OR=0.30, p=0.02). Broad clinical measures (cardiac arrest calls for peri-arrest situations and length of hospital stay) improved significantly in the areas covered by the new system. CONCLUSIONS The introduction of call handling software and mobile technology over a medical-grade wireless network improved staff satisfaction with the Hospital at Night system. Improvements in efficiency and information flow have been accompanied by a reduction in untoward incidents, length of stay and peri-arrest calls.
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Affiliation(s)
- John D Blakey
- Respiratory Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Debbie Guy
- City Hospital Campus, Nottingham NHS University Hospitals NHS Trust, Nottingham, UK
| | - Carl Simpson
- City Hospital Campus, Nottingham NHS University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Fearn
- City Hospital Campus, Nottingham NHS University Hospitals NHS Trust, Nottingham, UK
| | - Sharon Cannaby
- Health Sector Policy, Association of Chartered Certified Accountants, London, UK
| | - Petra Wilson
- European Health and Care Team, Internet Business Solutions Group, Cisco Systems, Brussels, Belgium
| | - Dominick Shaw
- Respiratory Biomedical Research Unit, University of Nottingham, Nottingham, UK
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Mason S. Keynote address: United Kingdom experiences of evaluating performance and quality in emergency medicine. Acad Emerg Med 2011; 18:1234-8. [PMID: 22168184 DOI: 10.1111/j.1553-2712.2011.01237.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Demand for emergency care is rising throughout the western world and represents a major public health problem. Increased reliance on professionalized health care by the public means that strategies need to be developed to manage the demand safely and in a way that is achievable and acceptable to both consumers of emergency care, but also to service providers. In the United Kingdom, strategies have previously been aimed at managing demand better and included introducing new emergency services for patients to access, extending the skills within the existing workforce, and more recently, introducing time targets for emergency departments (EDs). This article will review the effect of these strategies on demand for care and discuss the successes and failures with reference to future plans for tackling this increasingly difficult problem in health care.
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Affiliation(s)
- Suzanne Mason
- School of Health and Related Research, University of Sheffield, UK.
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