Evidence - Making a Difference
Improving care in general practice and reducing pressure on hospital services
There is increasing evidence that improving care in general practice and other interventions in the community can prevent pressure on the rest of the health care system. Below we have listed some of the current evidence – more is likely to appear over time.
WHAT INTERVENTIONS AVOID EMERGENCY OR UNPLANNED HOSPITAL ADMISSIONS?
The Kings Fund produced a paper in December 2010 considering the research evidence for a range of interventions to avoid emergency or unplanned hospital admissions ‘Avoiding hospital admissions: What does the research evidence say?’ Sarah Purdy, December 2010.
They found that evidence from the research literature suggests:
- People from lower socio-economic groups are at higher risk of avoidable emergency admissions.
- There are several tools available to help identify people at high risk of future emergency admission, including computer database models and simple questionnaires. There is no clear advantage of using one tool over another.
- It is important to be clear which admissions are potentially avoidable and which interventions are likely to be effective. Clarity of disease coding is essential.
- In primary care, higher continuity of care with a GP is associated with lower risk of
- Integrating health and social care may be effective in reducing admissions.
- Integrating primary and secondary care can be effective in reducing admissions.
- Telemedicine seems to be effective for patients with heart failure, but there is little evidence that it is effective for other conditions.
- Hospital at home produces similar outcomes to inpatient care, at a similar cost.
- Case management in the community and in hospital is not effective in reducing generic admissions. There is limited evidence to suggest that it may be effective for patients with heart failure. Assertive case management is beneﬁcial for patients with mental health problems.
- Patient self-management seems to be beneﬁcial.
- Acute assessment units may reduce avoidable admissions, but the overall impact on number of admissions should be considered.
- Early review by a senior clinician in the emergency department is effective. GPs working in the emergency department are probably effective in reducing admissions, but may not be cost-effective.
- There is a lack of evidence on the effectiveness of combinations of interventions.
A LINK BETWEEN CONTINUITY OF CARE WITH A PARTICULAR GP AND LOWER EMERGENCY ADMISSION RATES
A recent paper published on June 23, 2011 ‘Characteristics of general practices associated with emergency admission rates to hospital: a cross -sectional study’ (EmergMed J 2011; 28:558e563.doi:10.1136/emj.2010.108548) looked at 145 general practices across two PCTs in the East Midlands. It concluded that being able to consult a particular GP, an aspect of continuity, is associated with lower emergency admission rates. The results showed that certain practice characteristics (shorter distance from hospital, smaller list size) and patient characteristics (higher proportion of older people, white ethnicity, increasing deprivation, female gender) were associated with higher admission rates. There was no association with quality and outcomes framework domains (clinical or organisation), but there was an association between patients reporting being able to see a particular general practitioner (GP) and admission rates. As the proportion of patients able to consult a particular GP increased, emergency admission rates declined.
IMPROVING ACCESS TO GENERAL PRACTICE CAN CONTAIN THE USE OF EMERGENCY DEPARTMENTS
A related study, published on 16 June 2011 in BMJ Quality & Safety Online First, found that lower satisfaction with practice telephone access were associated with higher emergency-department attendance rates. It concluded that performance as indicated by the quality and outcomes framework did not predict rates of attendance at emergency departments, but satisfaction with telephone access did. Consideration should be given to improving access to some general practices to contain the use of emergency departments.
REDUCING EMERGENCY ADMISSIONS BY COLLABORATING ON HOME VISITS
There is the example, quoted in our original report, that highlights the potential for reducing emergency admissions by collaborating on home visits. An award-winning scheme in St Helens cut emergency admissions by 30%, saving £1m. A home visiting doctor service covers nine small practices (four were single-handed initially). Patients ring their regular practice and are called back promptly by their own doctor or practice nurse. Where the clinician judges the case to be urgent, it is put through to the doctor at the acute visiting service. Three-quarters of patients are seen within an hour and they get a longer consultation, averaging 20 minutes. The system uses the infrastructure of the local out of hours provider to make sure that relevant patient information is provided to the visiting doctor and that notes are fed back to the practice quickly. Patients value the early response and longer consultations, while for practices it has freed up clinical time, by about two or three appointments per surgery, without affecting continuity of care. Lead GP Dr Shikha Pitalia explains: ‘It prevents that situation when you either call an ambulance “in case” or you delay a visit, only to have a call from a relative later which leads to an admission that might have been avoidable.’
SHIFTING THE BALANCE OF CARE FROM HOSPITAL TO PRIMARY CARE AND IMPROVING ACCESS
In 1998 Roberts reviewed the literature and concluded that “shifting the balance of care” was possible between community and A&E. This article however highlighted the risks of unexpected consequences of simply transferring interventions which succeed in one setting without understanding the underlying processes of change. It appeared that the literature then suggested that a broadening of access to primary and community care could reduce demand on emergency departments. The 1998 New Zealand HTA review highlighted the fact that difficulty of access of primary care is often cited as a reason for attending the emergency department and that studies in the US have shown that improved access decreases ED attendance. However the US is markedly different and many of the studies related to providing low income families with access to primary care for the first time rather than using sporadic emergency department care, so lessons may not apply to the UK. Other Countries had also had similar findings including Israel (Porter et al 1988) and Sweden (Sjonell 1986 found a 40% reduction) with only two exceptions published at that time (Strauss et al 1983; Dodge 1983).
IMPORTANCE OF EARLY ASSESSMENT IN REDUCING HOSPITAL ADMISSIONS
Early assessment is an important element in ensuring that an urgent care system is safe for patients. The need for such an assessment is obvious in identifying immediately life-threatening conditions such as acute chest pain but there are many other common situations that primary care clinicians face in which timely assessment provides the opportunity to intervene early enough to deliver improved outcomes for patients. Examples include UTI amongst elderly patients where early intervention by primary care clinicians can prevent the development of more acute problems. There are good operational examples of targeted interventions and pathways for some high risk groups such as nursing home patients. Training for care assistants on recognition of UTI early in residents has been shown to reduce the admission rate of this group.
AVOIDING UNNECESSARY ADMISSIONS FOR PEOPLE WHO WANT TO DIE AT HOME
A paper in the London Journal in Primary Care ‘How to avoid Out of Hours admissions to hospital of patients who want to die at home’ Paul Thomas, September 2009, found that insufficient communication between those involved often acted as a barrier to people dying at home. It found that a series of steps could be taken to avoid undesirable hospital admission of a dying person who has a crisis in the out of hours period. These include creating a register of vulnerable adults, records at home, key workers, home interventions, day time practitioner communication, a development and governaqnce group, speedy discharge from hospital, and decision support for out of hours GPs.
REDUCING PRESSURE ON URGENT CARE CENTRES
More recently, we have seen 20% reduction in the Urgent Care Centre utilisation when we carried out an intervention in all the local practices. All practices reviewed their response to urgent care and changes were recommended on the basis of analysis of their activity and access.