Patricia Coleman

Effectiveness of emergency care practitioners working within existing emergency service models of care

Background: An emergency care practitioner (ECP) is a generic practitioner drawn mainly from paramedic and nursing backgrounds. ECPs receive formal training and extended clinical skills to equip them to work as an integral part of the healthcare team working within and across traditional boundaries of emergency and unplanned care. Currently, ECPs are working in different healthcare settings in the UK. Objectives: (1) To evaluate appropriateness, satisfaction and cost of ECPs compared with the usual service available in the same healthcare setting, (2) to increase understanding of what effect, if any, ECPs are having on delivery of health services locally and (3) to evaluate whether ECP working yields cost savings. Methods: Using a mixed-methods approach, data were collected quantitatively and qualitatively from three different types of health provider setting where ECPs are operational, in three areas of England. Data were collected by sending two questionnaires to each patient eligible to be seen by an ECP, at 3 and 28 days after presentation; telephone interviews were conducted with a sample of staff that included ECPs, other health professionals and stakeholders (eg, managers) in each of the three settings; and routine data were analysed to provide a perspective on costs. Results: After adjusting for age, sex, presenting complaint and service model, some differences in the processes of care between the ECPs and the usual providers in the three settings were observed. Overall, ECPs carried out fewer investigations, provided more treatments and were more likely to discharge patients home than the usual providers. Patients were satisfied with the care received from ECPs, and this was consistent across the three different settings. It was found that ECPs are working in different settings across traditional professional boundaries and are having an impact on reconfiguring how those services are delivered locally. Costs information (based on one site only) indicated that ECP care may be cost effective in that model of ECP working. Conclusion: Care provided by ECPs appears to reduce the need for subsequent referral to other emergency and unscheduled care services in a large proportion of cases. We found no evidence that the care provided by an ECP was less appropriate than the care by the usual providers for the same type of health problem.

Health and Health care Costs and Benefits of Exercise

To assess the value of promoting health through exercise, we review what is known about the medical and medical care resource costs and benefits of exercise. Literatu re searches were undertaken to derive estimates of the relati ve risk, in individuals who exercise regularl y compared with those who do not, of each of the major disease groups for which there is good evidence that the disease can be ameliorated by exercise (coronary heart disease. stroke. diabetes, hip frac ture, and mental illness). These relative risks were used to estimate the incidence of hospital admissions and mortality, and associated healthcare costs. which could be prevented if the whole population exercised. Literature on the incidence and costs of exercise-related morbidity and mortality was so reviewed to derive estimates of both the costs to health and also the healthcare resource implications of exercise in a total population. Indirect costs and benefits, and also quality-of-life effects associated with exercise were not included in this assessment.The results show that in younger adulls (ages 15 to 44 years) the average annual medical care costs per person that might be incurred as a result of full participation in sport and exercise (approximately £30) exceed the costs that might be avoided by the disease-prevention effects of exercise (<£5 per person). However, in older adults (2:45) the estimated costs avoided (>£30 per person) greatly outweigh the costs that would be incurred (£10). There was little evidence that exercise leads 10 deferred health or health se rvice resource benefits. We conclude that with regard 10 health and medical care costs, Ihere are slrong economic arguments in favour of exercise in adults aged 2:45 but not in younger adulls.Estimales derived from the international scientific literature and routine UK data sources may have limited direct application in the healthcare systems of other countries. Nevertheless, the result that exercise costs exceed the benefits in younger adults but vice versa in older people is likely to be generally true. Indeed, a similar result has been found in a study of a Dutch population.

Consensus methods to identify a set of potential performance indicators for systems of emergency and urgent care.

Objectives To identify a comprehensive set of indicators to enable Primary Care Trust (PCT) commissioners in England and other NHS decision-makers to monitor the performance of systems of emergency and urgent care for which they are responsible. Methods Using a combination of Delphi RAND methods in three successive rounds of consultation and nominal group review, we canvassed expert opinion on 70 potential indicators as good measures of system performance. The two Delphi panels consisted of senior clinicians and researchers, and urgent care leads and commissioners in PCTs and Strategic Health Authorities (SHAs). The indicators were formatted into a questionnaire according to whether they were outcome, process, structure, or equity-based measures. Participants scored each indicator on a Likert scale of 1-9 and had the opportunity to consider their scores informed by the group scores and feedback. The questionnaire was refined after each round. To ensure that the indicators rated most highly by the Delphi panels covered all dimensions of performance, the results of the Delphi were reviewed by a nominal group consisting of two researchers and three clinicians from the local health services research network (LHSR). Results Overall, the process yielded 16 candidate indicators. It also produced a core set of serious, emergency and urgent care-sensitive conditions (defined as conditions whose exacerbations should be managed by a well-performing system without admission to an inpatient bed), for use with the indicators. Conclusions System-wide measures to monitor performance across multiple services should encourage providers to work for patient benefit in an integrated way. They will also assist commissioners to monitor and improve emergency and urgent care for their local populations. The indicators are now being calculated using routinely available data, and tested for their responsiveness to capture change over time.

A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trial)

Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergency and urgent care settings. However, there is little evidence of the effectiveness of ECPs within these different settings. The aim of this study was to evaluate the impact of ECPs on patient pathways and care in different emergency care settings. Methods A pragmatic quasi-experimental multi-site community intervention trial comprising five matched pairs of intervention (ECP) and control services (usual care providers): ambulance, care home, minor injury unit, urgent care centre and GP out-of-hours. The main outcome being assessed was patient disposal pathway following the care episode. Results 5525 patient episodes (n=2363 intervention and n=3162 control) were included in the study. A significantly greater percentage of patients were discharged by ECPs working in mobile settings such as the ambulance service (percentage diff. 36.7%, 95% CI 30.8% to 42.7%) and care home service (36.8%, 26.7% to 46.8%). In static services such as out-of-hours (−17.9%, −30.8% to −42.7%) and urgent care centres (−11.5%, −18.0% to −5.1%), a significantly greater percentage of patients were discharged by usual care providers. Conclusions ECPs have a differential impact compared with usual care providers dependent on the operational service settings. Maximal impact occurs when they operate in mobile settings when care is taken to the patient. In these settings ECPs have a broader range of skills than the usual care providers (eg, paramedic), and are targeted to specific clinical groups who can benefit from alternative pathways of care (such as older people who have fallen). Trial Registration No ISRCTN22085282 (Controlled trials.com).