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Saunders C, Davies C, Sidhu M, Sussex J. Impact of vertical integration on patients' use of hospital services in England: an analysis of activity data. BJGP Open 2024:BJGPO.2023.0231. [PMID: 38191189 DOI: 10.3399/bjgpo.2023.0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Debate surrounding the organisation and sustainability of primary care in England highlights the desirability of a more integrated approach to patient care across all settings. One such approach is 'vertical integration', where a provider of specialist care, such as a hospital, also runs general practices. AIM To quantify the impact of vertical integration on hospital use in England. DESIGN & SETTING Analysis of activity data for NHS hospitals in England between April 2013 and February 2020. METHOD Analysis of NHS England data on hospital activity, which looked at the following seven outcome measures: accident and emergency (A&E) department attendances; outpatient attendances; total inpatient admissions; inpatient admissions for ambulatory care sensitive conditions; emergency admissions; emergency readmissions; and length of stay. Rates of hospital use by patients of vertically integrated practices and controls were compared, before and after the former were vertically integrated. RESULTS In the 2 years after a GP practice changes, for the population registered at that practice, compared with controls, vertical integration is associated with modest reductions in rates of A&E attendances (2% reduction [incidence rate ratio {IRR} 0.98, 95% confidence interval {CI} = 0.96 to 0.99, P<0.0001]), outpatient attendances (1% reduction [IRR 0.99, 95% CI = 0.99 to 1.00, P = 0.0061]), emergency inpatient admissions (3% reduction [IRR 0.97, 95% CI = 0.95 to 0.99, P = 0.0062]), and emergency readmissions within 30 days (5% reduction [IRR 0.95, 95% CI = 0.91 to 1.00, P = 0.039]), with no impact on length of stay, overall inpatient admissions, or inpatient admissions for ambulatory care sensitive conditions. CONCLUSION Vertical integration is associated with modest reductions in use of some hospital services and no change in others.
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Affiliation(s)
| | | | - Manbinder Sidhu
- University of Birmingham, Health Services Management Centre, Birmingham, UK
| | - Jon Sussex
- RAND Europe Community Interest Company, Cambridge, UK
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Exarchakou A, Rachet B, Lyratzopoulos G, Maringe C, Rubio FJ. What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England. Br J Cancer 2024:10.1038/s41416-024-02688-6. [PMID: 38671209 DOI: 10.1038/s41416-024-02688-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP. METHODS We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression. RESULTS Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it. CONCLUSIONS Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.
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Affiliation(s)
- Aimilia Exarchakou
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Camille Maringe
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Grigoroglou C, Walshe K, Kontopantelis E, Ferguson J, Stringer G, Ashcroft DM, Allen T. Comparing the clinical practice and prescribing safety of locum and permanent doctors: observational study of primary care consultations in England. BMC Med 2024; 22:126. [PMID: 38532468 DOI: 10.1186/s12916-024-03332-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
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.
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Affiliation(s)
- Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Jane Ferguson
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Gemma Stringer
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
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Kovacevic L, Naik R, Lugo-Palacios DG, Ashrafian H, Mossialos E, Darzi A. 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. Health Policy 2023; 138:104940. [PMID: 37976620 DOI: 10.1016/j.healthpol.2023.104940] [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: 04/20/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Lana Kovacevic
- NIHR Imperial Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, Queen Elizabeth Queen Mother Wing, St Mary's Hospital, South Wharf Road, W2 1NY, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK.
| | - Ravi Naik
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
| | - David G Lugo-Palacios
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Hutan Ashrafian
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
| | - Elias Mossialos
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Health Policy, London School of Economics and Political Science, Houghton Street, WC2A 2AE, London, UK
| | - Ara Darzi
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
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Conroy S, Brailsford S, Burton C, England T, Lalseta J, Martin G, Mason S, Maynou-Pujolras L, Phelps K, Preston L, Regen E, Riley P, Street A, van Oppen J. Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-183. [PMID: 37830206 DOI: 10.3310/nlct5104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Background We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design. Objective(s), study design, settings and participants Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions. Results A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality. Limitations Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly. Conclusions We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people. Future work Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs. Study registrations This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Conroy
- Geriatrician, George Davies Centre, University of Leicester, Leichester, UK
| | - Sally Brailsford
- Southampton Business School, University of Southampton, Southampton, UK
| | - Christopher Burton
- Academic Unit of Medical Education, University of Sheffield, Sheffield, UK
| | - Tracey England
- Health Sciences, University of Southampton, Southampton, UK
| | - Jagruti Lalseta
- Leicester Older Peoples' Research Forum, University of Leicester, Leicester, UK
| | - Graham Martin
- Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Louise Preston
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Riley
- Leicester older peoples' research forum, University of Leicester, Leicester, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics, London, UK
| | - James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
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Maynou L, Street A, Burton C, Mason SM, Stone T, Martin G, van Oppen J, Conroy S. Factors associated with longer wait times, admission and reattendances in older patients attending emergency departments: an analysis of linked healthcare data. Emerg Med J 2023; 40:248-256. [PMID: 36650039 PMCID: PMC10086302 DOI: 10.1136/emermed-2022-212303] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVE Care for older patients in the ED is an increasingly important issue with the ageing society. To better assess the quality of care in this patient group, we assessed predictors for three outcomes related to ED care: being seen and discharged within 4 hours of ED arrival; being admitted from ED to hospital and reattending the ED within 30 days. We also used these outcomes to identify better-performing EDs. METHODS The CUREd Research Database was used for a retrospective observational study of all 1 039 251 attendances by 368 754 patients aged 75+ years in 18 type 1 EDs in the Yorkshire and the Humber region of England between April 2012 and March 2017. We estimated multilevel logit models, accounting for patients' characteristics and contact with emergency services prior to ED arrival, time variables and the ED itself. RESULTS Patients in the oldest category (95+ years vs 75-80 years) were more likely to have a long ED wait (OR=1.13 (95% CI=1.10 to 1.15)), hospital admission (OR=1.26 (95% CI=1.23 to 1.29)) and ED reattendance (OR=1.09 (95% CI=1.06 to 1.12)). Those who had previously attended (3+ vs 0 previous attendances) were more likely to have long wait (OR=1.07 (95% CI=1.06 to 1.08)), hospital admission (OR=1.10 (95% CI=1.09 to 1.12)) and ED attendance (OR=3.13 (95% CI=3.09 to 3.17)). Those who attended out of hours (vs not out of hours) were more likely to have a long ED wait (OR=1.33 (95% CI=1.32 to 1.34)), be admitted to hospital (OR=1.19 (95% CI=1.18 to 1.21)) and have ED reattendance (OR=1.07 (95% CI=1.05 to 1.08)). Those living in less deprived decile (vs most deprived decile) were less likely to have any of these three outcomes: OR=0.93 (95% CI=0.92 to 0.95), 0.92 (95% CI=0.90 to 0.94), 0.86 (95% CI=0.84 to 0.88). These characteristics were not strongly associated with long waits for those who arrived by ambulance. Emergency call handler designation was the strongest predictor of long ED waits and hospital admission: compared with those who did not arrive by ambulance; ORs for these outcomes were 1.18 (95% CI=1.16 to 1.20) and 1.85 (95% CI=1.81 to 1.89) for those designated less urgent; 1.37 (95% CI=1.33 to 1.40) and 2.13 (95% CI=2.07 to 2.18) for urgent attendees; 1.26 (95% CI=1.23 to 1.28) and 2.40 (95% CI=2.36 to 2.45) for emergency attendees; and 1.37 (95% CI=1.28 to 1.45) and 2.42 (95% CI=2.26 to 2.59) for those with life-threatening conditions. We identified two EDs whose patients were less likely to have a long ED, hospital admission or ED reattendance than other EDs in the region. CONCLUSIONS Age, previous attendance and attending out of hours were all associated with an increased likelihood of exceeding 4 hours in the ED, hospital admission and reattendance among patients over 75 years. These differences were less pronounced among those arriving by ambulance. Emergency call handler designation could be used to identify those at the highest risk of long ED waits, hospital admission and ED reattendance.
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Affiliation(s)
- Laia Maynou
- Department of Econometrics, Statistics and Applied Economics, Universitat de Barcelona, Barcelona, Spain
- Department of Health Policy, The London School of Economics and Political Science, London, UK
- Center for Research in Health and Economics (CRES), Universitat Pompeu Fabra, Barcelona, Spain
| | - Andrew Street
- Department of Health Policy, The London School of Economics and Political Science, London, UK
| | - Christopher Burton
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Tony Stone
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Graham Martin
- THIS Institute, University of Cambridge, Cambridge, UK
| | - James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
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Thayer N, White S, Frisher M. Use of path analysis to predict changes to community pharmacy and GP emergency hormonal contraception (EHC) provision in England. BMJ Open 2022; 12:e059039. [PMID: 36418123 PMCID: PMC9723885 DOI: 10.1136/bmjopen-2021-059039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES In 2014/2015, 46% of community pharmacies were commissioned by local authorities to provide emergency hormonal contraception (EHC) free without prescription in England. Commissioning EHC services influences EHC prescribing from General Practice (GP)-greater community pharmacy provision reduces GP prescribing. This study aimed to examine predictors of GP and pharmacy EHC activity, describing them using path analysis. From this, commissioners and policy-makers may understand ways to influence this. STUDY DESIGN Cross-sectional study of routinely recorded data, obtained through freedom of information requests to local authorities. SETTING Community pharmacies and general practices in England, UK. PARTICIPANTS All local authorities in England were included in the study (147 areas). The study population were all girls, adolescents and women aged 12-55. Of the 147 areas, data from 80 local authorities were obtained covering an eligible female population of 9 380 153. PRIMARY AND SECONDARY OUTCOME MEASURES Correlation between community pharmacy and GP EHC activity. RESULTS Data from 80 local authorities were analysed, representing 60% of the eligible female population in England. A significant negative correlation was found between rates of community pharmacy provision and GP prescribing (-0.458, p<0.000). Community pharmacy provision and the proportion of pharmacies commissioned were significantly correlated (0.461, p<0.000). A significant correlation was found between increased deprivation and community pharmacy provision (0.287, p=0.010). Standardised total effects on GP prescribing were determined from path analysis including community pharmacy provision (ß=-0.552) and proportion of pharmacies commissioned (ß=-0.299). If all community pharmacies were commissioned to provide EHC, GP EHC prescriptions could decrease by 15%. CONCLUSION Community pharmacy EHC provision has a significant influence on GP EHC prescribing. Increasing the proportion of commissioned community pharmacies should have a marked impact on GP workload. The methodology affords the possibility of examining relationships surrounding other commissioned service activity across different settings and their impact on linked care settings.
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Affiliation(s)
- Nick Thayer
- School of Pharmacy, Keele University, Newcastle-under-Lyme, Staffordshire, UK
| | - Simon White
- School of Pharmacy, Keele University, Newcastle-under-Lyme, Staffordshire, UK
| | - Martin Frisher
- School of Pharmacy, Keele University, Newcastle-under-Lyme, Staffordshire, UK
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Park J, Yeo Y, Ji Y, Kim B, Han K, Cha W, Son M, Jeon H, Park J, Shin D. Factors Associated with Emergency Department Visits and Consequent Hospitalization and Death in Korea Using a Population-Based National Health Database. Healthcare (Basel) 2022; 10:healthcare10071324. [PMID: 35885850 PMCID: PMC9325044 DOI: 10.3390/healthcare10071324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/03/2022] [Accepted: 07/14/2022] [Indexed: 12/02/2022] Open
Abstract
We aim to investigate common diagnoses and risk factors for emergency department (ED) visits as well as those for hospitalization and death after ED visits. This study describes the clinical course of ED visits by using the 2014–2015 population data retrieved from the National Health Insurance Service. Sociodemographic, medical, and behavioral factors were analyzed through multiple logistic regression. Older people were more likely to be hospitalized or to die after an ED visit, but younger people showed a higher risk for ED visits. Females were at a higher risk for ED visits, but males were at a higher risk for ED-associated hospitalization and death. Individuals in the highest quartile of income had a lower risk of ED death relative to lowest income level individuals. Disabilities, comorbidities, and medical issues, including previous ED visits or prior hospitalizations, were risk factors for all ED-related outcomes. Unhealthy behaviors, including current smoking, heavy alcohol consumption, and not engaging in regular exercise, were also significantly associated with ED visits, hospitalization, and death. Common diagnoses and risk factors for ED visits and post-visit hospitalization and death found in this study provide a perspective from which to establish health polices for the emergency medical care system.
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Affiliation(s)
- Junhee Park
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea; (J.P.); (Y.J.)
| | - Yohwan Yeo
- Department of Family Medicine, College of Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong 18450, Korea
- Correspondence: (Y.Y.); (D.S.)
| | - Yonghoon Ji
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea; (J.P.); (Y.J.)
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Korea; (B.K.); (K.H.)
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Korea; (B.K.); (K.H.)
| | - Wonchul Cha
- Department of Emergency Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Meonghi Son
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Hongjin Jeon
- Department of Psychiatry, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Jaehyun Park
- Center for Wireless and Population Health System, University of California, La Jolla, San Diego, CA 92093, USA;
| | - Dongwook Shin
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea; (J.P.); (Y.J.)
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Science & Technology (SAIHST), School of Medicine, Sungkyunkwan University, Seoul 06355, Korea
- Correspondence: (Y.Y.); (D.S.)
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Svedahl ER, Pape K, Austad B, Vie GÅ, Anthun KS, Carlsen F, Bjørngaard JH. Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts. Fam Pract 2022; 39:381-388. [PMID: 34694363 PMCID: PMC9155163 DOI: 10.1093/fampra/cmab120] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use. OBJECTIVE To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety. METHODS This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design. RESULTS Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death. CONCLUSIONS GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.
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Affiliation(s)
- Ellen Rabben Svedahl
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristine Pape
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjarne Austad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnhild Åberge Vie
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjartan Sarheim Anthun
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Health Research, SINTEF Digital, Trondheim, Norway
| | - Fredrik Carlsen
- Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
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10
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Leitch S, Dovey S, Cunningham W, Wallis K, Eggleton K, Lillis S, McMenamin A, Williamson M, Reith D, Samaranayaka A, Tilyard M. Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study. BMJ Open 2021; 11:e048316. [PMID: 34253671 PMCID: PMC8276280 DOI: 10.1136/bmjopen-2020-048316] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/17/2022] Open
Abstract
OBJECTIVES To determine the epidemiology of healthcare harm observable in general practice records. DESIGN Retrospective cohort records review study. SETTING 72 general practice clinics were randomly selected from all 988 New Zealand clinics stratified by rurality and size; 44 clinics consented to participate. PARTICIPANTS 9076 patient records were randomly selected from participating clinics. INTERVENTION Eight general practitioners examined patient records (2011-2013) to identify harms, harm severity and preventability. Analyses were weighted to account for the stratified sampling design and generalise findings to all New Zealand patients. MAIN OUTCOME MEASURES Healthcare harm, severity and preventability. RESULTS Reviewers identified 2972 harms affecting 1505 patients aged 0-102 years. Most patients (82.0%, weighted) experienced no harm. The estimated incidence of harm was 123 per 1000 patient-years. Most harms (2160; 72.7%, 72.4% weighted) were minor, 661 (22.2%, 22.8% weighted) were moderate, and 135 (4.5%, 4.4% weighted) severe. Eleven patients died, five following a preventable harm. Of the non-fatal harms, 2411 (81.6%, 79.4% weighted) were considered not preventable. Increasing age and number of consultations were associated with increased odds of harm. Compared with patients aged ≤49 years, patients aged 50-69 had an OR of 1.77 (95% CI 1.61 to 1.94), ≥70 years OR 3.23 (95% CI 2.37 to 4.41). Compared with patients with ≤3 consultations, patients with 4-12 consultations had an OR of 7.14 (95% CI 5.21 to 9.79); ≥13 consultations OR 30.06 (95% CI 21.70 to 41.63). CONCLUSIONS Strategic balancing of healthcare risks and benefits may improve patient safety but will not necessarily eliminate harms, which often arise from standard care. Reducing harms considered 'not preventable' remains a laudable challenge.
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Affiliation(s)
- Sharon Leitch
- General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Susan Dovey
- General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | | | - Katharine Wallis
- Primary Care Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Kyle Eggleton
- General Practice and Primary Healthcare, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Steven Lillis
- Student Health, University of Waikato, Hamilton, New Zealand
| | | | - Martyn Williamson
- General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - David Reith
- Office of the Dean, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ariyapala Samaranayaka
- Preventive and Social Medicine, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Murray Tilyard
- General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
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11
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Palapar L, Kerse N, Wilkinson-Meyers L, Lumley T, Blom JW. Primary Care Variation in Rates of Unplanned Hospitalizations, Functional Ability, and Quality of Life of Older People. Ann Fam Med 2021; 19:318-331. [PMID: 34264838 PMCID: PMC8282304 DOI: 10.1370/afm.2687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 10/13/2020] [Accepted: 01/04/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To investigate variability in older people's outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands. METHODS We used data from 2 primary care-based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index. RESULTS None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, -0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, -1.64 to 0.97 QOL points in New Zealand; -0.01 EQ-5D points in the Netherlands). CONCLUSIONS In the absence of substantial differences in older people's function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.
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Affiliation(s)
- Leah Palapar
- Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ngaire Kerse
- Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Laura Wilkinson-Meyers
- Health Systems Section, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Thomas Lumley
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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12
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Are more GPs associated with a reduction in emergency hospital admissions? A quantitative study on GP referral in England. Br J Gen Pract 2021; 71:e287-e295. [PMID: 33685922 DOI: 10.3399/bjgp.2020.0737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/27/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Recent studies have found an association between access to primary care and accident and emergency attendances, with better access associated with fewer attendances. Analyses of an association with emergency admissions, however, have produced conflicting findings. AIM This study investigated whether emergency admission rates in an area are associated with 1) the number of GPs, and 2) mean size of GP practice. DESIGN AND SETTING Analysis was conducted utilising Hospital Episode Statistics, the numbers of GPs and GP practices, Office for National Statistics population data, Quality and Outcomes Framework prevalence data, and Index of Multiple Deprivation data, from 2004/2005 to 2011/2012, for all practices in England. METHOD Regression analysis of panel data with fixed effects to address 1) a potential two-way relationship between the numbers of GPs and emergency admissions, and 2) unobservable characteristics of GP practices. RESULTS There is not a statistically significant relationship between the number of GPs in a primary care trust area and the number of emergency admissions, when analysing all areas. In deprived areas, however, a higher number of GPs is associated with lower emergency admissions. There is also a lower emergency admission rate in areas in which practices are on average larger, holding GP supply constant. CONCLUSION An increase in GPs was found to reduce emergency admissions in deprived areas, but not elsewhere. Areas in which GPs are concentrated into larger practices showed reduced levels of emergency admissions, all else being equal.
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13
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Pak A, Gannon B. Do access, quality and cost of general practice affect emergency department use? Health Policy 2021; 125:504-511. [PMID: 33546911 DOI: 10.1016/j.healthpol.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 11/28/2022]
Abstract
Limited access, poor experience, and high out-of-pocket (OOP) costs of primary care services may lead to avoidable emergency department (ED) presentations. But, the evidence has been limited with most of the studies using surveys conducted in EDs. Using detailed health survey data of Australian women linked to multiple administrative datasets, we extend the literature by estimating the effects of access, costs, and experience of general practice (GP) services on the probability of ED attendance while accounting for a large set of health and socioeconomic covariates. Our findings suggest that improvements in access to primary care services can significantly reduce the demand for low acuity ED presentations. We also show that the impact of increased accessibility of GP services is expected to be the highest for socioeconomic vulnerable populations and patients whose access is the poorest. This evidence can be useful for the design of targeted policies aimed at improving access to doctors in particular areas that are socioeconomically disadvantaged and where medical skill shortages are significant. However, policies aimed at reduction in primary care OOP costs or improvement in the perception of GP quality are less likely to be effective in reducing the number of non-urgent ED presentations.
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Affiliation(s)
- Anton Pak
- James Cook University, Australian Institute of Tropical Health and Medicine, Australia; The University of Queensland, School of Economics, Australia.
| | - Brenda Gannon
- The University of Queensland, School of Economics, Australia; The University of Queensland, Centre for the Business and Economics of Health, Australia.
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14
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McCormick B, Nicodemo C, Redding S. Will policy to constrain GP referrals damage health? Evidence using practice level NHS emergency admissions administrative data. Soc Sci Med 2021; 270:113666. [PMID: 33445117 DOI: 10.1016/j.socscimed.2020.113666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/30/2020] [Accepted: 12/28/2020] [Indexed: 11/24/2022]
Abstract
Attempts to control hospital expenditure by managing down General Practitioner (GP) referrals are reoccurring features of UK health policy. However, despite the best efforts of GPs to benchmark referral criteria, patient health may be damaged and other costs created by constraining referrals to targets. This paper adopts an indirect method to indicate whether rationing practice referrals may damage population health by distorting the use of health resources away from patients' interests. We utilise a comprehensive database at practice level that allows us to explore the relationship between referrals and emergency admissions, using a panel fixed effects model of admissions that allows for the endogeneity of referrals. We find that practice referrals are positively and partially correlated with emergency admissions, which is consistent with time-varying practice-level sickness shocks driving the relationship between referrals and emergency care, rather than shocks to the practice willingness to refer, or to system reforms. In this environment, government policy to constrain referrals may make the elective care less responsive to practice-level variations in illness, and thereby lower health.
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Affiliation(s)
- Barry McCormick
- CHSEO, Nuffield Department of Primary Care Health Science, University of Oxford, United Kingdom
| | - Catia Nicodemo
- CHSEO, Nuffield Department of Primary Care Health Science, University of Oxford, and IZA, United Kingdom.
| | - Stuart Redding
- CHSEO, Nuffield Department of Primary Care Health Science, University of Oxford, United Kingdom
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15
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Advanced Access scheduling in general practice and use of primary care: a Danish population-based matched cohort study. BJGP Open 2020; 4:bjgpopen20X101091. [PMID: 33144371 PMCID: PMC7880182 DOI: 10.3399/bjgpopen20x101091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 11/20/2022] Open
Abstract
Background Advanced access scheduling (AAS) allows patients to receive care from their GP at the time chosen by the patient. AAS has shown to increase the accessibility to general practice, but little is known about how AAS implementation affects the use of in-hours and out-of-hours (OOH) services. Aim To describe the impact of AAS on the use of in-hours and OOH services in primary care. Design & setting A population-based matched cohort study using Danish register data. Method A total of 161 901 patients listed in 33 general practices with AAS were matched with 287 837 reference patients listed in 66 reference practices without AAS. Outcomes of interest were use of daytime face-to-face consultations, and use of OOH face-to-face and phone consultations in a 2-year period preceding and following AAS implementation. Results No significant differences were seen between AAS practices and reference practices. During the year following AAS implementation, the number of daytime face-to-face consultations was 3% (adjusted incidence rate ratio [aIRR] = 1.03; 95% confidence interval [CI] = 0.99 to 1.07) higher in the AAS practices compared with the number in the reference practices. Patients listed with an AAS practice had 2% (aIRR = 0.98; 95% CI = 0.92 to 1.04) fewer OOH phone consultations and 6% (aIRR = 0.94; 95% CI = 0.86 to 1.02) fewer OOH face-to-face consultations compared with patients listed with a reference practice. Conclusion This study showed no significant differences following AAS implementation. However, a trend was seen towards slightly higher use of daytime primary care and lower use of OOH primary care.
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16
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Fung CY, Tan ZM, Savage A, Rahim M, Osman F, Adnan M, Peleva E, Sam AH. Undergraduate exposure to patient presentations on the acute medical placement: a prospective study in a London teaching hospital. BMJ Open 2020; 10:e040575. [PMID: 33243804 PMCID: PMC7692979 DOI: 10.1136/bmjopen-2020-040575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To identify the availability and variability of learning opportunities through patient presentations on an acute medical placement at a teaching hospital. DESIGN A prospective study evaluating all acute admissions to the Acute Medical Unit over 14 days (336 hours). Clinical presentations and the day and time of admission were recorded and compared with the learning outcomes specified in the medical school curriculum. SETTING An Acute Medical Unit at a London teaching hospital. OUTCOMES (1) Number of clinical presentations to the Acute Medical Unit over 14 days and (2) differences between the availability and variation of admissions and presentations between in-hours and out-of-hours. RESULTS There were 359 admissions, representing 1318 presentations. Of those presentations, 76.6% were admitted out-of-hours and 23.4% in-hours. Gastrointestinal bleeding, tachycardia, oedema and raised inflammatory markers were over three times more common per hour out-of-hours than in-hours. Hypoxia was only seen out-of-hours. Important clinical presentations in the curriculum such as chest pain and hemiparesis were not commonly seen. CONCLUSIONS There is greater availability of presentations seen out-of-hours and a changing landscape of presentations seen in-hours. The out-of-hours presentation profile may be due to expanded community and specialist services. Medical schools need to carefully consider the timing and location of their clinical placements to maximise undergraduate learning opportunities.
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Affiliation(s)
- Chee Yeen Fung
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Zhin Ming Tan
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Adam Savage
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Mahdi Rahim
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Fatima Osman
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Mohammed Adnan
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Emilia Peleva
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Amir H Sam
- Imperial College School of Medicine, Imperial College London, London, UK
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17
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Rose TC, Adams NL, Whitehead M, Wickham S, O'Brien SJ, Hawker J, Taylor-Robinson DC, Violato M, Barr B. Neighbourhood unemployment and other socio-demographic predictors of emergency hospitalisation for infectious intestinal disease in England: A longitudinal ecological study. J Infect 2020; 81:736-742. [PMID: 32888980 PMCID: PMC7649336 DOI: 10.1016/j.jinf.2020.08.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/22/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022]
Abstract
We examined trends in infectious intestinal disease (IID) hospitalisations in England. Overall IID admission rates for children and older adults declined between 2012 & 2017. Increasing unemployment was associated with increasing IID admission rates. Healthcare access, underlying morbidity and ethnicity were also associated with IID rates. Policies should address inequalities in emergency IID hospitalisations.
Background Previous studies have observed that infectious intestinal disease (IID) related hospital admissions are higher in more deprived neighbourhoods. These studies have mainly focused on paediatric populations and are cross-sectional in nature. This study examines recent trends in emergency IID admission rates, and uses longitudinal methods to investigate the effects of unemployment (as a time varying measure of neighbourhood deprivation) and other socio-demographic characteristics on IID admissions for adults and children in England. Methods A longitudinal ecological analysis was performed using Hospital Episode Statistics on emergency hospitalisations for IID, collected over the time period 2012–17 across England. Analysis was conducted at the neighbourhood (Lower-layer Super Output Area) level for three age groups (0–14; 15–64; 65+ years). Mixed-effect Poisson regression models were used to assess the relationship between trends in neighbourhood unemployment and emergency IID admission rates, whilst controlling for measures of primary and secondary care access, underlying morbidity and the ethnic composition of each neighbourhood. Results From 2012–17, declining trends in emergency IID admission rates were observed for children and older adults overall, while rates increased for some sub-groups in the population. Each 1 percentage point increase in unemployment was associated with a 6.3, 2.4 and 4% increase in the rate of IID admissions per year for children [IRR=1.06, 95%CI 1.06–1.07], adults [IRR=1.02, 95%CI 1.02–1.03] and older adults [IRR=1.04, 95%CI 1.036–1.043], respectively. Increases in poor primary care access, the percentage of people from a Pakistani ethnic background, and the prevalence of long-term health problems, in a neighbourhood, were also associated with increases in IID admission rates. Conclusions Increasing trends in neighbourhood deprivation, as measured by unemployment, were associated with increases in emergency IID admission rates for children and adults in England, despite controlling for measures of healthcare access, underlying morbidity and ethnicity. Research is needed to improve understanding of the mechanisms that explain these inequalities, so that effective policies can be developed to reduce the higher emergency IID admission rates experienced by more disadvantaged communities.
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Affiliation(s)
- Tanith C Rose
- Department of Public Health, Policy and Systems, University of Liverpool, Waterhouse Building 2nd Floor Block F, Liverpool, UK.
| | - Natalie L Adams
- Department of Public Health, Policy and Systems, University of Liverpool, Waterhouse Building 2nd Floor Block F, Liverpool, UK
| | - Margaret Whitehead
- Department of Public Health, Policy and Systems, University of Liverpool, Waterhouse Building 2nd Floor Block F, Liverpool, UK
| | - Sophie Wickham
- Department of Public Health, Policy and Systems, University of Liverpool, Waterhouse Building 2nd Floor Block F, Liverpool, UK
| | - Sarah J O'Brien
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jeremy Hawker
- National Infection Service, Public Health England, Birmingham, UK
| | - David C Taylor-Robinson
- Department of Public Health, Policy and Systems, University of Liverpool, Waterhouse Building 2nd Floor Block F, Liverpool, UK
| | - Mara Violato
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Benjamin Barr
- Department of Public Health, Policy and Systems, University of Liverpool, Waterhouse Building 2nd Floor Block F, Liverpool, UK
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18
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Catzikiris N, Tapley A, Morgan S, van Driel M, Spike N, Holliday EG, Ball J, Henderson K, McArthur L, Magin P. Emergency department referral patterns of Australian general practitioner registrars: a cross-sectional analysis of prevalence, nature and associations. AUST HEALTH REV 2019; 43:21-28. [PMID: 29117892 DOI: 10.1071/ah17005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 09/28/2017] [Indexed: 11/23/2022]
Abstract
Objective Limited international evidence suggests general practice registrars' emergency department (ED) referral rates exceed those of established general practitioners (GPs). The aim of the present study was to fill an evidence gap by establishing the prevalence, nature and associations of Australian GP registrar ED referrals. Methods A cross-sectional analysis was performed of the Registrar Clinical Encounters in Training (ReCEnT) cohort study of GP registrars' consultation experiences, between 2010 and 2015. The outcome factor in logistic regression analysis was referral to an ED. Independent variables included patient-level, registrar-level, practice-level and consultation-level factors. Results In all, 1161 GP registrars (response rate 95.5%) contributed data from 166966 consultations, comprising 258381 individual problems. Based on responses, 0.5% of problems resulted in ED referral, of which nearly 25% comprised chest pain, abdominal pain and fractures. Significant (P < 0.05) associations of ED referral included patient age <15 and >34 years, the patient being new to the registrar, one particular regional training provider (RTP), in-consultation information or assistance being sought and learning goals being generated. Outer regional-, remote- or very remote-based registrars made significantly fewer ED referrals than more urban registrars. Of the problems referred to the ED, 45.5% involved the seeking of in-consultation information or assistance, predominantly from supervisors. Conclusions Registrars' ED referral rates are nearly twice those of established GPs. The findings of the present study suggest acute illnesses or injuries present registrars with clinical challenges and real learning opportunities, and highlight the importance of continuity of care, even for acute presentations. What is known about the topic? A GP's decision concerning continued community- versus hospital-based management of acute presentations demands careful consideration of a suite of factors, including implications for patient care and resource expenditure. General practice vocational training is a critical period for the development of GP registrars' long-term patterns of practice. Although limited international evidence suggests GP registrars and early career GPs refer patients to the ED at a higher rate than their more experienced peers, these studies involved small subject numbers and did not investigate associations of registrars making an ED referral. Relevant Australian studies focusing on GP registrars' ED referral patterns are lacking. What does this paper add? The present ongoing cohort study is the first to establish the patterns of ED referrals made by Australian GP registrars, encompassing five general practice RTPs across five states, with participating registrars practising in urban, rural, remote and very remote practices. Several significant associations were found with GP registrars making ED referrals, including patient age, continuity of care, the registrar's RTP, assistance sought by the registrar and rurality of the registrar's practice. What are the implications for practitioners? The higher likelihood of GP registrars seeing acute presentations than their more established practice colleagues, coupled with a demonstrated association of registrars seeking in-consultation assistance for such presentations, highlights the importance of GP supervisor accessibility in facilitating ED referral appropriateness and in the development of registrars' safe clinical practice.
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Affiliation(s)
- Nigel Catzikiris
- GP Synergy, NSW and ACT Research and Evaluation Unit, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia. ;
| | - Amanda Tapley
- GP Synergy, NSW and ACT Research and Evaluation Unit, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia. ;
| | - Simon Morgan
- GP Synergy, NSW and ACT Research and Evaluation Unit, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia. ;
| | - Mieke van Driel
- Discipline of General Practice, School of Medicine, University of Queensland, Level 8 Health Sciences Building, Royal Brisbane and Women's Hospital, Brisbane, Qld 4029, Australia
| | - Neil Spike
- Eastern Victoria GP Training, 15 Cato Street, Hawthorn, Vic. 3122, Australia. Email
| | - Elizabeth G Holliday
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Jean Ball
- Public Health Research Program, Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW 2305, Australia.
| | - Kim Henderson
- GP Synergy, NSW and ACT Research and Evaluation Unit, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia. ;
| | - Lawrie McArthur
- Discipline of General Practice, University of Adelaide, 183 Melbourne Street, North Adelaide, SA 5006, Australia. Email
| | - Parker Magin
- GP Synergy, NSW and ACT Research and Evaluation Unit, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia. ;
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19
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Mendonca SC, Abel GA, Gildea C, McPhail S, Peake MD, Rubin G, Singh H, Hamilton W, Walter FM, Roland MO, Lyratzopoulos G. Associations between general practice characteristics with use of urgent referrals for suspected cancer and endoscopies: a cross-sectional ecological study. Fam Pract 2019; 36:573-580. [PMID: 30541076 PMCID: PMC6781939 DOI: 10.1093/fampra/cmy118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Large variation in measures of diagnostic activity has been described previously between English general practices, but related predictors remain understudied. OBJECTIVE To examine associations between general practice population and characteristics, with the use of urgent referrals for suspected cancer, and use of endoscopy. METHODS Cross-sectional observational study of English general practices. We examined practice-level use (/1000 patients/year) of urgent referrals for suspected cancer, gastroscopy, flexible sigmoidoscopy and colonoscopy. We used mixed-effects Poisson regression to examine associations with the sociodemographic profile of practice populations and other practice attributes, including the average age, sex and country of qualification of practice doctors. RESULTS The sociodemographic characteristics of registered patients explained much of the between-practice variance in use of urgent referrals (32%) and endoscopic investigations (18-25%), all being higher in practices with older and more socioeconomically deprived patients. Practice-level attributes explained a substantial amount of between-practice variance in urgent referral (19%) but little of the variance in endoscopy (3%-4%). Adjusted urgent referral rates were higher in training practices and those with younger GPs. Practices with mean doctor ages of 41 and 57 years (at the 10th/90th centiles of the national distribution) would have urgent referral rates of 24.1 and 19.1/1000 registered patients, P < 0.001. CONCLUSION Most between-practice variation in use of urgent referrals and endoscopies seems to reflect health need. Some practice characteristics, such as the mean age of GPs, are associated with appreciable variation in use of urgent referrals, though these associations do not seem strong enough to justify targeted interventions.
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Affiliation(s)
- Silvia C Mendonca
- The Health Improvement Institute (THIS), University of Cambridge, Cambridge, UK
| | - Gary A Abel
- University of Exeter Medical School (Primary Care), Exeter, UK
| | - Carolynn Gildea
- National Cancer Analysis and Registration Service (NCRAS), Public Health England, London, UK
| | - Sean McPhail
- National Cancer Analysis and Registration Service (NCRAS), Public Health England, London, UK
| | - Michael D Peake
- National Cancer Analysis and Registration Service (NCRAS), Public Health England, London, UK
- University of Leicester, Leicester, UK
| | - Greg Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Newcastle upon Tyne, UK
| | - Hardeep Singh
- Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Willie Hamilton
- University of Exeter Medical School (Primary Care), Exeter, UK
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Martin O Roland
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Georgios Lyratzopoulos
- The Health Improvement Institute (THIS), University of Cambridge, Cambridge, UK
- National Cancer Analysis and Registration Service (NCRAS), Public Health England, London, UK
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, UK
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20
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Blinkenberg J, Pahlavanyali S, Hetlevik Ø, Sandvik H, Hunskaar S. General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study. BMC Health Serv Res 2019; 19:568. [PMID: 31412931 PMCID: PMC6693245 DOI: 10.1186/s12913-019-4419-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/09/2019] [Indexed: 12/11/2022] Open
Abstract
Background Primary care doctors have a gatekeeper function in many healthcare systems, and strategies to reduce emergency hospital admissions often focus on general practitioners’ (GPs’) and out-of-hours (OOH) doctors’ role. The aim of the present study was to investigate these doctors’ role in emergency admissions to somatic hospitals in the Norwegian public healthcare system, where GPs and OOH doctors have a distinct gatekeeper function. Methods A cross-sectional analysis was performed by linking data from the Norwegian Patient Registry (NPR) and the physicians’ claims database. The referring doctor was defined as the physician who had sent a claim for a consultation with the patient within 24 h prior to an emergency admission. If there was no claim registered prior to hospital arrival, the admission was defined as direct, representing admissions from ambulance services, referrals from nursing home doctors, and admissions initiated by in-hospital doctors. Results In 2014 there were 497,587 emergency admissions to somatic hospitals in Norway after excluding birth related conditions. Direct admissions were most frequent (43%), 31% were referred by OOH doctors, 25% were referred by GPs, whereas only 2% were referred from outpatient clinics or private specialists with public contract. Direct admissions were more common in central areas (52%), here GPs’ referrals constituted only 16%. The prehospital paths varied with the hospital discharge diagnosis. For anaemias, 46–49% were referred by GPs, for acute appendicitis and mental/alcohol related disorders 52 and 49% were referred by OOH doctors, respectively. For both malignant neoplasms and cardiac arrest 63% were direct admissions. Conclusions GPs or OOH doctors referred many emergencies to somatic hospitals, and for some clinical conditions GPs’ and OOH doctors’ gatekeeping role was substantial. However, a significant proportion of the emergency admissions was direct, and this reduces the impact of the GPs’ and OOH doctors’ gatekeeper roles, even in a strict gatekeeping system.
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Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway.
| | - Sahar Pahlavanyali
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
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Lynch B, Fitzgerald AP, Corcoran P, Buckley C, Healy O, Browne J. Drivers of potentially avoidable emergency admissions in Ireland: an ecological analysis. BMJ Qual Saf 2018; 28:438-448. [PMID: 30314977 DOI: 10.1136/bmjqs-2018-008002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Many emergency admissions are deemed to be potentially avoidable in a well-performing health system. OBJECTIVE To measure the impact of population and health system factors on county-level variation in potentially avoidable emergency admissions in Ireland over the period 2014-2016. METHODS Admissions data were used to calculate 2014-2016 age-adjusted emergency admission rates for selected conditions by county of residence. Negative binomial regression was used to identify which a priori factors were significantly associated with emergency admissions for these conditions and whether these factors were also associated with total/other emergency admissions. Standardised incidence rate ratios (IRRs) associated with a 1 SD change in risk factors were reported. RESULTS Nationally, potentially avoidable emergency admissions for the period 2014-2016 (266 395) accounted for 22% of all emergency admissions. Of the population factors, a 1 SD change in the county-level unemployment rate was associated with a 24% higher rate of potentially avoidable emergency admissions (IRR: 1.24; 95% CI 1.04 to 1.41). Significant health system factors included emergency admissions with length of stay equal to 1 day (IRR: 1.20; 95% CI 1.11 to 1.30) and private health insurance coverage (IRR: 0.92; 95% CI 0.89 to 0.96). The full model accounted for 50% of unexplained variation in potentially avoidable emergency admissions in each county. Similar results were found across total/other emergency admissions. CONCLUSION The results suggest potentially avoidable emergency admissions and total/other emergency admissions are primarily driven by socioeconomic conditions, hospital admission policy and private health insurance coverage. The distinction between potentially avoidable and all other emergency admissions may not be as useful as previously believed when attempting to identify the causes of regional variation in emergency admission rates.
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Affiliation(s)
- Brenda Lynch
- School of Public Health, University College Cork, Cork, Ireland
| | | | - Paul Corcoran
- School of Public Health, University College Cork, Cork, Ireland
| | - Claire Buckley
- School of Public Health, University College Cork, Cork, Ireland
| | - Orla Healy
- Public Health, Health Service Executive South, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
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22
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Neill S, Roland D, Thompson M, Tavaré A, Lakhanpaul M. Why are acute admissions to hospital of children under 5 years of age increasing in the UK? Arch Dis Child 2018; 103:917-919. [PMID: 29475836 DOI: 10.1136/archdischild-2017-313958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Sarah Neill
- Faculty of Health and Society, University of Northampton, Northampton, UK
| | - Damian Roland
- Health Sciences, University of Leicester, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Hospitals, Leicester, UK
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, Washington, USA.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alison Tavaré
- West of England Academic Health Science Network, Bristol, UK
| | - Monica Lakhanpaul
- General and Adolescent Paediatrics Unit, UCL Institute of Child Health, London, UK
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McCormick B, Hill PS, Redding S. Comparative morbidities and the share of emergencies in hospital admissions in deprived areas: a method and evidence from English administrative data. BMJ Open 2018; 8:e022573. [PMID: 30127052 PMCID: PMC6104760 DOI: 10.1136/bmjopen-2018-022573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Various studies find that the share of emergencies in hospital admissions is higher in deprived areas, but both the explanation and policy implications are unclear. We estimate the extent to which this finding is due to a different disease mix in deprived areas, rather than other explanations such as patient behaviour and general practitioner effectiveness. DESIGN Secondary analysis using English Hospital Episode Statistics data, with disease for elective and emergency admissions in 2008/2009 coded at 186 blocks or 1230 categories and aggregated to lower layer super output area of residence. It is then linked to an appropriate measure of deprivation. OUTCOME MEASURES The difference in the share of emergencies in hospital admissions between communities in the highest and lowest deciles of deprivation; and the percentage of this difference that is explained if areas in the least deprived decile have the same disease mix as those in the most deprived decile. RESULTS Using the finest disease classification scheme (1230 categories), 71% of the higher share of admissions that were emergencies in decile 1 areas relative to decile 10, is explained by the "adverse" case mix (CM) in deprived areas. The remainder reflects the higher relative use of emergency care in deprived areas for the same conditions. Higher incidence of respiratory and circulatory diseases in deprived areas explains about 30% of the CM contribution. Diseases of the digestive system and abdomen have a high relative use of emergency care in deprived areas. CONCLUSIONS The higher use of emergency care in deprived areas is primarily a symptom of the higher prevalence of diseases which have high national rates of emergency to elective care-especially respiratory diseases-rather than an indication of less effective primary care. Nevertheless, there is a higher share of emergency care in admissions in deprived areas for several diseases, most notably of the digestive system.
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Affiliation(s)
- Barry McCormick
- Centre for Health Service Economics & Organisation, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter-Sam Hill
- Education Portfolio, Oxford Policy Management, Oxford, UK
| | - Stuart Redding
- Centre for Health Service Economics & Organisation, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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24
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Maringe C, Pashayan N, Rubio FJ, Ploubidis G, Duffy SW, Rachet B, Raine R. Trends in lung cancer emergency presentation in England, 2006-2013: is there a pattern by general practice? BMC Cancer 2018; 18:615. [PMID: 29855264 PMCID: PMC5984417 DOI: 10.1186/s12885-018-4476-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/02/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Emergency presentations (EP) represent over a third of all lung cancer admissions in England. Such presentations usually reflect late stage disease and are associated with poor survival. General practitioners (GPs) act as gate-keepers to secondary care and so we sought to understand the association between GP practice characteristics and lung cancer EP. METHODS Data on general practice characteristics were extracted for all practices in England from the Quality Outcomes Framework, the Health and Social Care Information Centre, the GP Patient Survey, the Cancer Commissioning Toolkit and the area deprivation score for each practice. After linking these data to lung cancer patient registrations in 2006-2013, we explored trends in three types of EP, patient-led, GP-led and 'other', by general practice characteristics and by socio-demographic characteristics of patients. RESULTS Overall proportions of lung cancer EP decreased from 37.9% in 2006 to 34.3% in 2013. Proportions of GP-led EP nearly halved during this period, from 28.3 to 16.3%, whilst patient-led emergency presentations rose from 62.1 to 66.7%. When focusing on practice-specific levels of EP, 14% of general practices had higher than expected proportions of EP at least once in 2006-13, but there was no evidence of clustering of patients within practice, meaning that none of the practice characteristics examined explained differing proportions of EP by practice. CONCLUSION We found that the high proportion of lung cancer EP is not the result of a few practices with very abnormal patterns of EP, but of a large number of practices susceptible to reaching high proportions of EP. This suggests a system-wide issue, rather than problems with specific practices. High proportions of lung cancer EP are mainly the result of patient-initiated attendances in A&E. Our results demonstrate that interventions to encourage patients not to bypass primary care must be system wide rather than targeted at specific practices.
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Affiliation(s)
- Camille Maringe
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - Nora Pashayan
- University College London, Department of Applied Health Research, London, UK
| | - Francisco Javier Rubio
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - George Ploubidis
- Centre for Longitudinal Studies, Department of Social Science, UCL - Institute of Education, University College London, London, UK
| | - Stephen W. Duffy
- Queen Mary University of London, Wolfson Institute of Preventive Medicine, Centre for Cancer Prevention, London, UK
| | - Bernard Rachet
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - Rosalind Raine
- University College London, Department of Applied Health Research, London, UK
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25
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Cowling TE, Majeed A, Harris MJ. Patient experience of general practice and use of emergency hospital services in England: regression analysis of national cross-sectional time series data. BMJ Qual Saf 2018; 27:643-654. [PMID: 29358314 DOI: 10.1136/bmjqs-2017-007174] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 12/11/2017] [Accepted: 12/19/2017] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Thomas E Cowling
- Department of Primary Care and Public Health, Imperial College London, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Matthew J Harris
- Department of Primary Care and Public Health, Imperial College London, London, UK
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26
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Leitch S, Dovey SM, Samaranayaka A, Reith DM, Wallis KA, Eggleton KS, McMenamin AW, Cunningham WK, Williamson MI, Lillis S, Tilyard MW. Characteristics of a stratified random sample of New Zealand general practices. J Prim Health Care 2018; 10:114-124. [DOI: 10.1071/hc17089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
ABSTRACT INTRODUCTION Practice size and location may affect the quality and safety of health care. Little is known about contemporary New Zealand general practice characteristics in terms of staffing, ownership and services. AIM To describe and compare the characteristics of small, medium and large general practices in rural and urban New Zealand. METHODS Seventy-two general practices were randomly selected from the 2014 Primary Health Organisation database and invited to participate in a records review study. Forty-five recruited practices located throughout New Zealand provided data on staff, health-care services and practice ownership. Chi-square and other non-parametric statistical analyses were used to compare practices. RESULTS The 45 study practices constituted 4.6% of New Zealand practices. Rural practices were located further from the nearest regional base hospital (rural median 65.0 km, urban 7.5 km (P < 0.001)), nearest local hospital (rural 25.7 km, urban 7.0 km (P = 0.002)) and nearest neighbouring general practitioner (GP) (rural 16.0 km, urban 1.0 km (P = 0.007)). In large practices, there were more enrolled patients per GP FTE than both medium-sized and small practices (mean 1827 compared to 1457 and 1120 respectively, P = 0.019). Nurses in large practices were more likely to insert intravenous lines (P = 0.026) and take blood (P = 0.049). There were no significant differences in practice ownership arrangements according to practice size or rurality. CONCLUSION Study practices were relatively homogenous. Unsurprisingly, rural practices were further away from hospitals. Larger practices had higher patient-to-doctor ratios and increased nursing scope. The study sample is small; findings need to be confirmed by specifically powered research.
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27
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Tammes P, Purdy S, Salisbury C, MacKichan F, Lasserson D, Morris RW. Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England. Ann Fam Med 2017; 15:515-522. [PMID: 29133489 PMCID: PMC5683862 DOI: 10.1370/afm.2136] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 05/11/2017] [Accepted: 06/05/2017] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Secondary health care services have been under considerable pressure in England as attendance rates increase, resulting in longer waiting times and greater demands on staff. This study's aim was to examine the association between continuity of care and risk of emergency hospital admission among older adults. METHODS We analyzed records from 10,000 patients aged 65 years and older in 2012 within 297 English general practices obtained from the Clinical Practice Research Datalink and linked with Hospital Episode Statistics. We used the Bice and Boxerman (BB) index and the appointed general practitioner index (last general practitioner consulted before hospitalization) to quantify patient-physician continuity. The BB index was used in a prospective cohort approach to assess impact of continuity on risk of admission. Both indices were used in a separate retrospective nested case-control approach to test the effect of changing physician on the odds of hospital admission in the following 30 days. RESULTS In the prospective cohort analysis, the BB index showed a graded, non-significant inverse relationship of continuity of care with risk of emergency hospital admission, although the hazard ratio for patients experiencing least continuity was 2.27 (95% CI, 1.37-3.76) compared with those having complete continuity. In the retrospective nested case-control analysis, we found a graded inverse relationship between continuity of care and emergency hospital admission for both BB and appointed general practitioner indices: for the latter, the odds ratio for those experiencing least continuity was 2.32 (95% CI, 1.48-3.63) relative to those experiencing most continuity. CONCLUSIONS Marked discontinuity of care might contribute to increased unplanned hospital admissions among patients aged 65 years and older. Schemes to enhance continuity of care have the potential to reduce hospital admissions.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sarah Purdy
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Fiona MacKichan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Daniel Lasserson
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Department of Gerontology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, Oxford, United Kingdom
| | - Richard W Morris
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Busby J, Purdy S, Hollingworth W. How do population, general practice and hospital factors influence ambulatory care sensitive admissions: a cross sectional study. BMC FAMILY PRACTICE 2017; 18:67. [PMID: 28545412 PMCID: PMC5445441 DOI: 10.1186/s12875-017-0638-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/11/2017] [Indexed: 11/21/2022]
Abstract
Background Reducing unplanned hospital admissions is a key priority within the UK and other healthcare systems, however it remains uncertain how this can be achieved. This paper explores the relationship between unplanned ambulatory care sensitive condition (ACSC) admission rates and population, general practice and hospital characteristics. Additionally, we investigated if these factors had a differential impact across 28 conditions. Methods We used the English Hospital Episode Statistics to calculate the number of unplanned ACSC hospital admissions for 28 conditions at 8,029 general practices during 2011/12. We used multilevel negative binomial regression to estimate the influence of population (deprivation), general practice (size, access, continuity, quality, A&E proximity) and hospital (bed availability, % day cases) characteristics on unplanned admission rates after adjusting for age, sex and chronic disease prevalence. Results Practices in deprived areas (at the 90th centile) had 16% (95% confidence interval: 14 to 18) higher admission rates than those in affluent areas (10th centile). Practices with poorer care continuity (9%; 8 to 11), located closest to A&E (8%; 6 to 9), situated in areas with high inpatient bed availability (14%; 10 to 18) or in areas with a larger proportion of day case admissions (17%; 12 to 21) had more admissions. There were smaller associations for primary care access, clinical quality, and practice size. The strength of associations varied by ACSC. For example, deprivation was most strongly associated with alcohol related diseases and COPD admission rates, while continuity of primary care was most strongly associated with admission rates for chronic diseases such as hypertension and iron-deficiency anaemia. Conclusions The drivers of unplanned ACSC admission rates are complex and include population, practice and hospital factors. The importance of these varies markedly across conditions suggesting that multifaceted interventions are required to avoid hospital admissions and reduce costs. Several of the most important drivers of admissions are largely beyond the control of GPs. However, strategies to improve primary care continuity and avoid unnecessary short-stay admissions could lead to improved efficiency. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0638-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John Busby
- Centre for Public Health, Queen's University Belfast, BT12 6BA, Belfast, UK.
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, BS8 2PS, Bristol, UK
| | - William Hollingworth
- School of Social and Community Medicine, University of Bristol, BS8 2PS, Bristol, UK
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Socioeconomic deprivation and accident and emergency attendances: cross-sectional analysis of general practices in England. Br J Gen Pract 2016; 65:e649-54. [PMID: 26412841 DOI: 10.3399/bjgp15x686893] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
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.
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30
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Opportunities for primary care to reduce hospital admissions: a cross-sectional study of geographical variation. Br J Gen Pract 2016; 67:e20-e28. [PMID: 27777230 DOI: 10.3399/bjgp16x687949] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/07/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Reducing unplanned hospital admissions is a key priority within the UK. Substantial interpractice variation in admission rates for ambulatory care sensitive conditions (ACSC) suggests that decreases might be possible. AIM To identify the clinical areas and patient subgroups where the greatest opportunities exist for GPs to improve ACSC care. DESIGN AND SETTING Cross-sectional study using routine hospital data from patients registered at 8123 English GP practices during 2011 and 2012. METHOD The authors used random effects Poisson models to estimate interpractice variation after adjusting for several drivers of healthcare need and availability of local hospital services. Interpractice variation was contrasted across patient subgroups based on age. RESULTS There were 1.8 million hospital admissions. Overall, high-utilisation practices had ACSC admission rates that were 55% (95% CI = 53 to 56) greater than low-utilisation practices. Differences of 67% (95% CI = 65 to 69) were found for chronic ACSCs, which was much larger than the 51% (95% CI = 49 to 52) difference exhibited by acute presentations. At least two-fold differences were found for 15 (54%) ACSCs, although large interpractice variations were not ubiquitous. Admission rates were consistently more variable among younger-than-average patients. The most variable conditions tended to disproportionately affect deprived patients. CONCLUSION Substantial interpractice variation suggests that current efforts to standardise primary care have had a limited effect on unplanned hospital admissions. GPs and healthcare commissioners should ensure they are offering best practice care for the most variable clinical areas and patient subgroups identified in the study, particularly in adults aged <70 years with chronic conditions.
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31
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Conway R, Byrne D, O'Riordan D, Cournane S, Coveney S, Silke B. Influence of social deprivation, overcrowding and family structure on emergency medical admission rates. QJM 2016; 109:675-680. [PMID: 27118873 DOI: 10.1093/qjmed/hcw053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/18/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients from deprived backgrounds have a higher in-patient mortality following emergency medical admission. AIM To evaluate the influence of Deprivation Index, overcrowding and family structure on hospital admission rates. DESIGN Retrospective cohort study. METHODS All emergency medical admissions from 2002 to 2013 were evaluated. Based on address, each patient was allocated to an electoral division, whose small area population statistics were available from census data. Patients were categorized by quintile of Deprivation Index, overcrowding and family structure, and these were evaluated against hospital admission rate, calculated as rate/1000 population. Univariate and multivariable risk estimates (Odds Ratios or Incidence Rate Ratios) were calculated, using logistic or zero truncated Poisson regression as appropriate. RESULTS There were 66 861 admissions in 36 214 patients over the 12-year study period. Deprivation Index quintile independently predicted the admission rate, with rates of Q1 12.0 (95% CI 11.8-12.2), Q2 19.5 (95% CI 19.3-19.6), Q3 33.7 (95% CI 33.3-34.0), Q4 31.4 (95% CI 31.2-31.6) and Q5 38.1 (95% CI 37.7-38.5). Similarly the proportions of families with children <15 years old, was an independent predictor of the admission rate with rates of Q1 20.8 (95% CI 20.4-21.1), Q2 23.0 (95% CI 22.7-23.3), Q3 32.2 (95% CI 31.9-32.5), Q4 32.4 (95% CI 32.2-32.7) and Q5 37.2 (95% CI 36.6-37.8). The proportion of families with children ≥15-years old was also predictive but quintile of overcrowding was only predictive in the univarate model. CONCLUSION Deprivation Index and family structure strongly predict emergency medical hospital admission rates.
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Affiliation(s)
- R Conway
- From the Department of Internal Medicine St James's Hospital, Dublin 8, Ireland
- CARD Newman Research Fellow, University College Dublin, Belfield, Ireland
| | - D Byrne
- From the Department of Internal Medicine St James's Hospital, Dublin 8, Ireland
| | - D O'Riordan
- From the Department of Internal Medicine St James's Hospital, Dublin 8, Ireland
| | - S Cournane
- From the Department of Internal Medicine St James's Hospital, Dublin 8, Ireland
| | - S Coveney
- School of Geographical and Earth Sciences, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK
| | - B Silke
- From the Department of Internal Medicine St James's Hospital, Dublin 8, Ireland
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Barker I, Lloyd T, Steventon A. Effect of a national requirement to introduce named accountable general practitioners for patients aged 75 or older in England: regression discontinuity analysis of general practice utilisation and continuity of care. BMJ Open 2016; 6:e011422. [PMID: 27638492 PMCID: PMC5030554 DOI: 10.1136/bmjopen-2016-011422] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To assess the effect of introducing named accountable general practitioners (GPs) for patients aged 75 years on patterns of general practice utilisation, including continuity of care. DESIGN Regression discontinuity design applied to data from the Clinical Practice Research Datalink to estimate the treatment effect for compliers aged 75. SETTING 200 general practices in England. PARTICIPANTS 255 469 patients aged between 65 and 85, after excluding those aged 75. INTERVENTION From April 2014, general practices in England were required to offer patients aged 75 or over a named accountable GP. This study compared having named accountable GPs for patients aged just over 75 with usual care provided for patients just under 75. OUTCOMES Number of contacts (face-to-face or telephone) with GPs, longitudinal continuity of care (usual provider of care, or UPC, index), number of referrals to specialist care and numbers of common diagnostic tests. Outcomes were measured over 9 months following assignment to a named accountable GP and for a comparable period for those unassigned. RESULTS The proportion of patients with a named accountable GP increased from 3.5% to 79.8% at age 75. No statistically significant effects were detected for continuity of care (estimated treatment effect 0.00, 95% CI -0.01 to 0.02) or the number of GP contacts per person (estimated treatment effect -0.11, 95% CI -0.31 to 0.09) over 9 months. No significant change was seen in the number of referrals, blood pressure or HbA1c diagnostic tests per person. A statistically significant treatment effect of -0.05 cholesterol tests per person (95% CI -0.07 to -0.02) was estimated; however, sensitivity analysis indicated that this effect predated the introduction of named accountable GPs. CONCLUSIONS Continuity of care is valued by patients, but the named accountable GP initiative did not improve continuity of care or change patterns of GP utilisation in the first 9 months of the policy.
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Affiliation(s)
- Isaac Barker
- Data Analytics, The Health Foundation, London, 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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Assessing Impacts on Unplanned Hospitalisations of Care Quality and Access Using a Structural Equation Method: With a Case Study of Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13090870. [PMID: 27598184 PMCID: PMC5036703 DOI: 10.3390/ijerph13090870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/09/2016] [Accepted: 08/23/2016] [Indexed: 11/16/2022]
Abstract
Background: Enhanced quality of care and improved access are central to effective primary care management of long term conditions. However, research evidence is inconclusive in establishing a link between quality of primary care, or access, and adverse outcomes, such as unplanned hospitalisation. Methods: This paper proposes a structural equation model for quality and access as latent variables affecting adverse outcomes, such as unplanned hospitalisations. In a case study application, quality of care (QOC) is defined in relation to diabetes, and the aim is to assess impacts of care quality and access on unplanned hospital admissions for diabetes, while allowing also for socio-economic deprivation, diabetes morbidity, and supply effects. The study involves 90 general practitioner (GP) practices in two London Clinical Commissioning Groups, using clinical quality of care indicators, and patient survey data on perceived access. Results: As a single predictor, quality of care has a significant negative impact on emergency admissions, and this significant effect remains when socio-economic deprivation and morbidity are allowed. In a full structural equation model including access, the probability that QOC negatively impacts on unplanned admissions exceeds 0.9. Furthermore, poor access is linked to deprivation, diminished QOC, and larger list sizes. Conclusions: Using a Bayesian inference methodology, the evidence from the analysis is weighted towards negative impacts of higher primary care quality and improved access on unplanned admissions. The methodology of the paper is potentially applicable to other long term conditions, and relevant when care quality and access cannot be measured directly and are better regarded as latent variables.
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Pereira Gray D, Sidaway-Lee K, White E, Thorne A, Evans P. Improving continuity: THE clinical challenge. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/1755738016654504] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Continuity of care is a core feature of general practice; it creates multiple benefits for patients, doctors and society. Continuity increases trust, patient satisfaction, disclosure of information, take-up of preventive care, adherence to advice, reduction in socio-economic disadvantage, and reduces deaths. However, the level of continuity is reducing in general practice. About 15 consultations are needed with a patient for a GP to acquire enough ‘accumulated knowledge’ to develop a sense of continuing responsibility. This fosters GP sensitivity and mutual understanding, which enable GPs to provide ‘higher-level’ quality of care. The RCGP curriculum states two high-level aims: that GPs need to ‘enhance continuity of care’ and ‘build long-term relationships with patients’. This article analyses these aims by setting them in the context of international research on continuity of care.
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Affiliation(s)
- Denis Pereira Gray
- Consultant, St Leonard’s Practice, Exeter and Former Chairman of Council and President of the RCGP
| | | | - Eleanor White
- Medical Student, University of Exeter Medical School, Exeter
| | - Angus Thorne
- BSc Student, University of Exeter Medical School, Exeter
| | - Philip Evans
- Senior Partner and Research Lead at St Leonard’s Practice and NIHR Clinical Research Network (CRN) National Cluster Lead for Primary Care, Mental Health, Public Health and Dermatology. National Specialty Lead for Primary Care within the CRN
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Baker R, Walker N. Extended opening hours in primary care: helpful for patients and-or-a distraction for health professionals? BMJ Qual Saf 2016; 26:347-349. [PMID: 27435190 DOI: 10.1136/bmjqs-2016-005415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2016] [Indexed: 11/03/2022]
Affiliation(s)
- Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola Walker
- Department of Health Sciences, University of Leicester, Leicester, UK
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Emergency hospital admissions for asthma and access to primary care: cross-sectional analysis. Br J Gen Pract 2016; 66:e640-6. [PMID: 27324628 DOI: 10.3399/bjgp16x686089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 01/27/2016] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Access to general practices may be an important determinant of emergency admissions for asthma, as early treatment of exacerbations has been shown to prevent deterioration. AIM To determine whether access to primary care is associated with emergency admissions for asthma. DESIGN AND SETTING Cross-sectional analysis of data from English practices in 2010-2011. METHOD Negative binomial regression was used to explore the associations between emergency admissions for asthma and seven measures of patient-reported access to general practice services taken from the GP Patient Survey, controlled for the characteristics of practice populations. Incidence rate ratios (IRR) were calculated for each association. RESULTS In total 7806 (95%) of practices had data for all variables. There were 3 134 106 patients with asthma, and there were 55 570 emergency admissions with asthma. Admission rates were lower in practices with a higher composite access score (adjusted IRR for 10% change in variable 0.679, 95% CI = 0.665 to 0.708). Admissions were higher in those practices with higher proportions of the practice population who were white, and in practices with lower performance in the Quality and Outcomes Framework indicator 'asthma review in past 15 months' (Asthma 6). Assuming these associations were causal, a higher access score of 10% was associated with a decrease of 17 837 admissions per year for these practices. CONCLUSION Practices with higher patient-reported access had lower rates of emergency admissions for asthma. Policymakers should consider improving access to primary care as one potential way to help prevent emergency hospital admissions for asthma.
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Ford JA, Wong G, Jones AP, Steel N. Access to primary care for socioeconomically disadvantaged older people in rural areas: a realist review. BMJ Open 2016; 6:e010652. [PMID: 27188809 PMCID: PMC4874140 DOI: 10.1136/bmjopen-2015-010652] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of this review is to identify and understand the contexts that effect access to high-quality primary care for socioeconomically disadvantaged older people in rural areas. DESIGN A realist review. DATA SOURCES MEDLINE and EMBASE electronic databases and grey literature (from inception to December 2014). ELIGIBILITY CRITERIA FOR SELECTING STUDIES Broad inclusion criteria were used to allow articles which were not specific, but might be relevant to the population of interest to be considered. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded for concepts relating to context, mechanism or outcome. ANALYSIS An overarching patient pathway was generated and used as the basis to explore contexts, causal mechanisms and outcomes. RESULTS 162 articles were included. Most were from the USA or the UK, cross-sectional in design and presented subgroup data by age, rurality or deprivation. From these studies, a patient pathway was generated which included 7 steps (problem identified, decision to seek help, actively seek help, obtain appointment, get to appointment, primary care interaction and outcome). Important contexts were stoicism, education status, expectations of ageing, financial resources, understanding the healthcare system, access to suitable transport, capacity within practice, the booking system and experience of healthcare. Prominent causal mechanisms were health literacy, perceived convenience, patient empowerment and responsiveness of the practice. CONCLUSIONS Socioeconomically disadvantaged older people in rural areas face personal, community and healthcare barriers that limit their access to primary care. Initiatives should be targeted at local contextual factors to help individuals recognise problems, feel welcome, navigate the healthcare system, book appointments easily, access appropriate transport and have sufficient time with professional staff to improve their experience of healthcare; all of which will require dedicated primary care resources.
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Affiliation(s)
- John A Ford
- Department of Public Health and Primary Care, University of East Anglia, Norwich, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andy P Jones
- Department of Public Health and Primary Care, University of East Anglia, Norwich, UK
| | - Nick Steel
- Department of Public Health and Primary Care, University of East Anglia, Norwich, UK
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Effect of Named, Accountable GPs on Continuity of Care: Protocol for a Regression Discontinuity Study of a National Policy Change. Int J Integr Care 2016; 16:6. [PMID: 27616950 PMCID: PMC5015538 DOI: 10.5334/ijic.2450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction: Increasing continuity of care has been identified as a
strategy to improve patient outcomes, but previous studies of integrated care
have tended to focus on pilot areas, which limit their generalisability and the
ability to determine in which contexts integrated care was most successful. Objective: This study protocol describes a quantitative evaluation
of a reform in England that introduced named, accountable general practitioners
for all National Health Service (NHS) patients aged 75 years or over. The
national contract for general practice services required that named general
practitioners offer longitudinal continuity of care within the general practice
and be accountable for coordinating care to meet the patient’s healthcare
needs. Methods: This study will apply a regression discontinuity design to
pseudonymised electronic medical records from a sample of general practices in
England. We will compare outcomes for patients aged just below and above the age
of 75 to estimate the effect of named general practitioners and relate these
estimated treatment effects to the characteristics of general practices.
Outcomes will include a metric relating to continuity of care, namely the Usual
Provider of Care Index, and numbers of general practitioner contacts, referrals
to specialist care and diagnostic tests. Discussion: The study illustrates an approach to evaluate national
changes aimed at more integrated care using electronic records, which will
complement in-depth examination in pilot sites.
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40
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Hunter LC, Lee RJ, Butcher I, Weir CJ, Fischbacher CM, McAllister D, Wild SH, Hewitt N, Hardie RM. Patient characteristics associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (COPD) following primary care COPD diagnosis: a cohort study using linked electronic patient records. BMJ Open 2016; 6:e009121. [PMID: 26801463 PMCID: PMC4735181 DOI: 10.1136/bmjopen-2015-009121] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To investigate patient characteristics of an unselected primary care population associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). DESIGN Retrospective open cohort using pseudonymised electronic primary care data linked to secondary care data. SETTING Primary care; Lothian (population approximately 800,000), Scotland. PARTICIPANTS Data from 7002 patients from 72 general practices with a COPD diagnosis date between 2000 and 2008 recorded in their primary care record. Patients were followed up until 2010, death or they left a participating practice. MAIN OUTCOME MEASURES First and subsequent admissions for AECOPD (International Classification of Diseases (ICD) 10 codes J44.0, J44.1 in any diagnostic position) after COPD diagnosis in primary care. RESULTS 1756 (25%) patients had at least 1 AECOPD admission; 794 (11%) had at least 1 readmission and the risk of readmission increased with each admission. Older age at diagnosis, more severe COPD, low body mass index (BMI), current smoking, increasing deprivation, COPD admissions and interventions for COPD prior to diagnosis in primary care, and comorbidities were associated with higher risk of first AECOPD admission in an adjusted Cox proportional hazards regression model. More severe COPD and COPD admission prior to primary care diagnosis were associated with increased risk of AECOPD readmission in an adjusted Prentice-Williams-Peterson model. High BMI was associated with a lower risk of first AECOPD admission and readmission. CONCLUSIONS Several patient characteristics were associated with first AECOPD admission in a primary care cohort of people with COPD but fewer were associated with readmission. Prompt diagnosis in primary care may reduce the risk of AECOPD admission and readmission. The study highlights the important role of primary care in preventing or delaying a first AECOPD admission.
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Affiliation(s)
- L C Hunter
- Department of Public Health and Health Policy, NHS Lothian, Edinburgh, Midlothian, UK
| | - R J Lee
- Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, Midlothian, UK
| | - I Butcher
- Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, Midlothian, UK
| | - C J Weir
- Reader in Medical Statistics and Associate Director (Statistics) Health Services Research Unit, Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, Midlothian, UK
| | - C M Fischbacher
- Clinical Director for Information Services, Information Services Division (ISD), NHS National Services Scotland, Edinburgh, Midlothian, UK
| | - D McAllister
- Usher Institute of Population Health Sciences and Informatics, Medical School, University of Edinburgh, Edinburgh, Midlothian, UK
| | - S H Wild
- Usher Institute of Population Health Sciences and Informatics, Medical School, University of Edinburgh, Edinburgh, Midlothian, UK
| | - N Hewitt
- Clinical Lead, Lothian Respiratory Managed Clinical Network, NHS Lothian, Edinburgh, Midlothian, UK
| | - R M Hardie
- Department of Public Health and Health Policy, NHS Lothian, Edinburgh, Midlothian, UK
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Butler M, Kim H, Sansone R. Improved continuity of care in a resident clinic. CLINICAL TEACHER 2016; 14:45-48. [PMID: 26748569 DOI: 10.1111/tct.12489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND For residents in the out-patient clinic, continuity in patient care is an integral and vital aspect of internal medicine training, but is frequently compromised by resident in-patient schedules, the structure of the out-patient clinic and the need to comply with the increasing regulation of duty hours. METHOD In this study, we examined whether the creation and implementation of a new team approach, the Firms Model, would improve the continuity of patient care in the internal medicine resident out-patient clinic. RESULTS Before the implementation of the Firms Model, an examination of a consecutive clinic sample indicated that patients were seen by their assigned resident providers 41.9 per cent of the time (n = 1319 clinic visits). After implementation of the Firms Model, an examination of a consecutive clinic sample indicated that patients were seen by their assigned Firm resident providers 88.9 per cent of the time (n = 1341 clinic visits). CONCLUSION Implementation of the Firms Model resulted in a statistically significant increase in the percentage of patients seen by assigned resident providers in an internal medicine out-patient clinic, culminating in a substantial improvement in continuity of care within our resident out-patient clinic. We discuss the implications of these findings. Continuity in patient care is an integral and vital aspect of internal medicine training, but is frequently compromised.
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Affiliation(s)
- Melissa Butler
- Department of Internal Medicine, Kettering Medical CenterDayton, Ohio, USA
| | - Hyungkoo Kim
- Department of Internal Medicine, Kettering Medical CenterDayton, Ohio, USA
| | - Randy Sansone
- Department of Internal Medicine, Kettering Medical CenterDayton, Ohio, USA
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Conway R, Byrne D, O'Riordan D, Cournane S, Coveney S, Silke B. Deprivation index and dependency ratio are key determinants of emergency medical admission rates. Eur J Intern Med 2015; 26:709-13. [PMID: 26412675 DOI: 10.1016/j.ejim.2015.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 08/25/2015] [Accepted: 09/10/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients from deprived backgrounds have a higher in-patient mortality following an emergency medical admission; there has been debate as to the extent to which deprivation and population structure influences hospital admission rate. METHODS All emergency medical admissions to an Irish hospital over a 12-year period (2002-2013) categorized by quintile of Deprivation Index and Dependency Ratio (proportion of population <15 or ≥ 65 years) from small area population statistics (SAPS), were evaluated against hospital admission rates. Univariate and multivariable risk estimates (Odds Ratios (OR) or Incidence Rate Ratios (IRR)) were calculated, using logistic or zero truncated Poisson regression as appropriate. RESULTS 66,861 admissions in 36,214 patients occured during the study period. The Deprivation Index quintile independently predicted the admission rate/1000 population, Q1 9.4 (95%CI 9.2 to 9.7), Q2 16.8 (95%CI 16.6 to 17.0), Q3 33.8 (95%CI 33.5 to 34.1), Q4 29.6 (95%CI 29.3 to 29.8) and Q5 45.4 (95%CI 44.5 to 46.2). Similarly the population Dependency Ratio was an independent predictor of the admission rate with adjusted predicted rates of Q1 20.8 (95%CI 20.5 to 21.1), Q2 19.2 (95%CI 19.0 to 19.4), Q3 27.6 (95%CI 27.3 to 27.9), Q4 43.9 (95%CI 43.5 to 44.4) and Q5 34.4 (95%CI 34.1 to 34.7). A high concurrent Deprivation Index and Dependency Ratio were associated with very high admission rates. CONCLUSION Deprivation Index and population Dependency Ratio are key determinants of the rate of emergency medical admissions.
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Affiliation(s)
- Richard Conway
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland; CARD Newman Research Fellow, University College Dublin, Belfield, Ireland
| | - Declan Byrne
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
| | - Deirdre O'Riordan
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
| | - Seán Cournane
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
| | - Seamus Coveney
- School of Geographical and Earth Sciences, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Bernard Silke
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland.
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Dusheiko M, Gravelle H, Martin S, Smith PC. Quality of Disease Management and Risk of Mortality in English Primary Care Practices. Health Serv Res 2015; 50:1452-71. [PMID: 25597263 PMCID: PMC4600356 DOI: 10.1111/1475-6773.12283] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To investigate whether better management of chronic conditions by family practices reduces mortality risk. DATA Two random samples of 5 million patients registered with over 8,000 English family practices followed up for 4 years (2004/5-2007/8). Measures of the quality of disease management for 10 conditions were constructed for each family practice for each year. The outcome measure was an indicator taking the value 1 if the patient died during a specified year, 0 otherwise. STUDY DESIGN Cross-section and multilevel panel data multiple logistic regressions were estimated. Covariates included age, gender, morbidity, hospitalizations, attributed socio-economic characteristics, and local health care supply measures. PRINCIPAL FINDINGS Although a composite measure of the quality of disease management for all 10 conditions was significantly associated with lower mortality, only the quality of stroke care was significant when all 10 quality measures were entered in the regression. CONCLUSIONS The panel data results suggest that a 1 percent improvement in the quality of stroke care could reduce the annual number of deaths in England by 782 [95 percent CI: 423, 1140]. A longer study period may be necessary to detect any mortality impact of better management of other conditions.
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Affiliation(s)
- Mark Dusheiko
- Centre for Health Economics, University of York, York, UK
- Institut d'économie et management de la santé, Internef Bureau 532 Université de Lausanne, Lausanne, Switzerland
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Stephen Martin
- Department of Economics and Related Studies, University of York, York, UK
| | - Peter C Smith
- Imperial College Business School, Imperial College, London, UK
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O'Cathain A, Knowles E, Turner J, Hirst E, Goodacre S, Nicholl J. Variation in avoidable emergency admissions: multiple case studies of emergency and urgent care systems. J Health Serv Res Policy 2015; 21:5-14. [PMID: 26248621 DOI: 10.1177/1355819615596543] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify factors affecting variation in avoidable emergency admissions that are not usually identified in statistical regression. METHODS As part of an ethnographic residual analysis, we compared six emergency and urgent care systems in England, interviewing 82 commissioners and providers of key emergency and urgent care services. RESULTS There was variation between the six cases in how interviewees described three parts of their emergency and urgent care systems. First, interviewees' descriptions revealed variation in the availability of services before patients decided to attend emergency departments. Poor availability of general practice out of hours services in some of the cases reportedly made attendance at emergency departments the easier option for patients. Second, there was variation in how interviewees described patients being dealt with during their emergency department visit in terms of availability of senior review by specialists and in coding practices when patients were at risk of breaching the NHS's 4-hour waiting time target. Third, there was variability in services described as facilitating discharge home from emergency departments. In some cases, emergency department staff described dealing with multiple agencies in multiple localities outside the hospital, making admission the easier option. In other cases, proactive multidisciplinary rapid assessment teams were described as available to avoid admissions. Perceptions of resources available out of hours and the extent of integration between different health services, and between health and social services, also differed by case. CONCLUSIONS This comparative case study approach identified further factors that may affect avoidable emergency admissions. Initiatives to improve GP out of hours services, make coding more accurately reflect patient experience, increase senior review in emergency departments, offer proactive multidisciplinary admission avoidance teams, improve the availability of out of hours care in the wider emergency and urgent care system, and increase service integration may reduce avoidable admissions. Evaluation of such initiatives would be necessary before wide-scale adoption.
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Affiliation(s)
- Alicia O'Cathain
- Professor of Health Services Research, School of Health and Related Research, University of Sheffield, UK
| | - Emma Knowles
- Research Fellow, School of Health and Related Research, University of Sheffield, UK
| | - Janette Turner
- Senior Research Fellow, School of Health and Related Research, University of Sheffield, UK
| | - Enid Hirst
- Chair of Sheffield Emergency Care Forum, Sheffield, UK
| | - Steve Goodacre
- Professor of Emergency Medicine, School of Health and Related Research, University of Sheffield, UK
| | - Jon Nicholl
- Professor of Health Services Research, School of Health and Related Research, University of Sheffield, 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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Affiliation(s)
- Denis Pereira Gray
- National Association for Patient Participation, Dennington, Ridgeway, Horsell, Woking GU21 4QR, UK.
| | - Patricia Wilkie
- National Association for Patient Participation, Dennington, Ridgeway, Horsell, Woking GU21 4QR, UK
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Campbell J, Warren F, Taylor R, Green C, Salisbury C. Patient perspectives on telephone triage in general practice - authors' reply. Lancet 2015; 385:688. [PMID: 25706213 DOI: 10.1016/s0140-6736(15)60283-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- John Campbell
- University of Exeter Medical School, Exeter, Devon EX1 2LU, UK.
| | - Fiona Warren
- University of Exeter Medical School, Exeter, Devon EX1 2LU, UK
| | - Rod Taylor
- University of Exeter Medical School, Exeter, Devon EX1 2LU, UK
| | - Colin Green
- University of Exeter Medical School, Exeter, Devon EX1 2LU, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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O’Cathain A, Knowles E, Turner J, Maheswaran R, Goodacre S, Hirst E, Nicholl J. Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02480] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundRecent 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.ObjectiveWe aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.MethodsThe 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.ResultsThe 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.ConclusionsDeprivation 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.FundingThe National Institute for Health Research Health Service and Research Delivery programme.
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Affiliation(s)
- Alicia O’Cathain
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Janette Turner
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ravi Maheswaran
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Enid Hirst
- Sheffield Emergency Care Forum, Sheffield, UK
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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District-level primary care supply buffers the negative impact of functional limitations on illness perceptions in older adults with multiple illnesses. Ann Behav Med 2014; 49:463-72. [PMID: 25416178 DOI: 10.1007/s12160-014-9671-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Illness perceptions predict important outcomes, e.g. coping, adherence and well-being. Less is known about the sources of illness perceptions, in particular the role of environmental factors such as primary care supply. PURPOSE This study examines whether and how primary care supply (on district level) affects individual illness perceptions. METHODS We conducted a longitudinal study in 271 adults 65 years and older with multiple illnesses. Functional limitations (SF-36 physical functioning subscale) at time 1 were tested as predictors of illness perceptions 6 months later. Primary care supply on district level was matched to individual data. RESULTS In multilevel models, functional limitations predicted illness perceptions. Primary care supply on district level moderated the impact of functional limitations on individual identity and emotional response perceptions, with better supply buffering detrimental effects of functional limitations. CONCLUSIONS Illness perceptions do not only depend on individual factors, but socio-structural factors also substantially contribute to individual illness perceptions.
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Honeyford K, Baker R, Bankart MJG, Jones DR. Estimating smoking prevalence in general practice using data from the Quality and Outcomes Framework (QOF). BMJ Open 2014; 4:e005217. [PMID: 25031192 PMCID: PMC4120299 DOI: 10.1136/bmjopen-2014-005217] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To determine to what extent underlying data published as part of Quality and Outcomes Framework (QOF) can be used to estimate smoking prevalence within practice populations and local areas and to explore the usefulness of these estimates. DESIGN Cross-sectional, observational study of QOF smoking data. Smoking prevalence in general practice populations and among patients with chronic conditions was estimated by simple manipulation of QOF indicator data. Agreement between estimates from the integrated household survey (IHS) and aggregated QOF-based estimates was calculated. The impact of including smoking estimates in negative binomial regression models of counts of premature coronary heart disease (CHD) deaths was assessed. SETTING Primary care in the East Midlands. PARTICIPANTS All general practices in the area of study were eligible for inclusion (230). 14 practices were excluded due to incomplete QOF data for the period of study (2006/2007-2012/2013). One practice was excluded as it served a restricted practice list. MEASUREMENTS Estimates of smoking prevalence in general practice populations and among patients with chronic conditions. RESULTS Median smoking prevalence in the practice populations for 2012/2013 was 19.2% (range 5.8-43.0%). There was good agreement (mean difference: 0.39%; 95% limits of agreement (-3.77, 4.55)) between IHS estimates for local authority districts and aggregated QOF register estimates. Smoking prevalence estimates in those with chronic conditions were lower than for the general population (mean difference -3.05%), but strongly correlated (Rp=0.74, p<0.0001). An important positive association between premature CHD mortality and smoking prevalence was shown when smoking prevalence was added to other population and service characteristics. CONCLUSIONS Published QOF data allow useful estimation of smoking prevalence within practice populations and in those with chronic conditions; the latter estimates may sometimes be useful in place of the former. It may also provide useful estimates of smoking prevalence in local areas by aggregating practice based data.
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Affiliation(s)
- Kate Honeyford
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - M John G Bankart
- Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - David R Jones
- Department of Health Sciences, University of Leicester, Leicester, UK
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