Peter Tammes

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice

Objectives To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). Design Ethnographic case study combining non-participant observation, informal and formal interviewing. Setting Six general practitioner (GP) practices located in three commissioning organisations in England. Participants and methods Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). Results Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like ‘urgent’ and ‘emergency’ was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. Conclusions This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around ‘inappropriate’ patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

Use of primary care data to predict those most vulnerable to cold weather: a case-crossover analysis

Background The National Institute for Health and Care Excellence (NICE) recommends that GPs use routinely available data to identify patients most at risk of death and ill health from living in cold homes. Aim To investigate whether sociodemographic characteristics, clinical factors, and house energy efficiency characteristics could predict cold-related mortality. Design and setting A case-crossover analysis was conducted on 34 777 patients aged ≥65 years from the Clinical Practice Research Datalink who died between April 2012 and March 2014. The average temperature of date of death and 3 days previously were calculated from Met Office data. The average 3-day temperature for the 28th day before/after date of death were calculated, and comparisons were made between these temperatures and those experienced around the date of death. Method Conditional logistic regression was applied to estimate the odds ratio (OR) of death associated with temperature and interactions between temperature and sociodemographic characteristics, clinical factors, and house energy efficiency characteristics, expressed as relative odds ratios (RORs). Results Lower 3-day temperature was associated with higher risk of death (OR 1.011 per 1°C fall; 95% CI = 1.007 to 1.015; P<0.001). No modifying effects were observed for sociodemographic characteristics, clinical factors, and house energy efficiency characteristics. Analysis of winter deaths for causes typically associated with excess winter mortality (N = 7710) showed some evidence of a weaker effect of lower 3-day temperature for females (ROR 0.980 per 1°C, 95% CI = 0.959 to 1.002, P = 0.082), and a stronger effect for patients living in northern England (ROR 1.040 per 1°C, 95% CI = 1.013 to 1.066, P = 0.002). Conclusion It is unlikely that GPs can identify older patients at highest risk of cold-related death using routinely available data, and NICE may need to refine its guidance.

Continuity of primary care matters and should be protected

Continuity could be a key line of defence against rising hospital admissions

Exploring the Relationship between General Practice Characteristics and Attendance at Walk-in Centres, Minor Injuries Units and Emergency Departments in England 2009/10 - 2012/2013: a Longitudinal Study

BackgroundThe UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates.MethodsA longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients’ emergency attendance rates and patients’ reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time.ResultsPractice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (−0.26 per 1% increase, 95%CI −0.45 to −0.08).ConclusionPractices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use.

Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England

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.

Investigating Differences in Brexit-vote Among Local Authorities in the UK: An Ecological Study on Migration- and Economy-related Issues:

During a non-binding referendum on the UK’s membership in the European Union in June 2016, 51.9% of UK voters voted in favour of leaving the European Union, also known as Brexit. However, the Local Authorities in the UK showed a wide variation in the referendum outcome. For 380 Local Authorities, the European Union referendum outcome was linked to data derived from the 2011 Census, creating a database to investigate associations between local factors and the referendum outcome. This ecological study formulated and tested hypotheses related to migration and economic issues as those two topics dominated the European Union referendum campaign. The results of multivariable generalised linear model analyses showed that the percentage of migrants who arrived between 2004 and 2011 in local areas was positively associated with the proportion of Leave-votes. This indicates that the relative number of recently arrived migrants might have been a key factor in voters’ decisions. Further research might focus on the origin of those migrants. Furthermore, in England, the percentage of lower educated was positively associated with the proportion of Leave-votes. This indicates that England was divided along educational lines. Moreover, this study also found a positive association between the proportion of elderly with self-reported poorer general health and the proportion of Leave-votes. Although investigating local health outcomes was beyond the study’s aim, this result indicates that health issues might be of importance in understanding local differences in European Union referendum outcomes. These findings provide us with a better understanding of the underlying factors of the Brexit-vote and directions for future research.

OP49 Association between temperature and death among elderly people in england 2012/13–2013/14: a case-crossover design

Background Around 24 000 extra deaths occur annually in winter in England and Wales. NICE guidance suggests GPs should identify patients most at risk. We investigated whether socio-demographic and clinical characteristics could predict cold-related mortality. Methods Data on over 5 00 000 patients aged 65+from the Clinical Practice Research Datalink (CPRD) were linked with ONS death registration, yielding 34 777 patients who died between April 2012 and March 2014. We used daily temperature data from the Met Office to calculate (i) absolute mean temperature and (ii) difference from average monthly temperature (relative temperature) for the date of death and three days previously. In a case-crossover analysis, we also calculated both temperature measures for the 14th day before and the 14th day after the date of death. Patients assumed to live in an institution were identified using the CPRD family number. From linked Hospital Episode Statistics, we determined whether an emergency hospital admission occurred two years before death to indicate previous health status. Deprivation level and house energy efficiency were determined from patient’s and practice’s Lower Super Output Area respectively: the latter used information from the Centre for Sustainable Energy. Conditional logistic regression models were applied to estimate the odds ratio (OR) of death associated with temperature and interactions between temperature and socio-demographic, medical and house quality characteristics were expressed as relative odds ratios (RORs). Results Higher absolute temperature was associated with lower risk of death (OR 0.985 per 1°C; 95% CI 0.975–0.992; p=<0.001). There was weak evidence of a positive association between risk of death and higher relative temperature (OR 1.008 per 1°C; 95% CI 0.999–1.017; p=0.056). No interactions were found between temperature measures and age, gender, living in urban/rural areas, deprivation level, or house energy efficiency in either bivariable or multivariable analyses. There was some evidence for a stronger effect of higher relative temperature for those living in an institution (ROR 1.025; 95% CI 1.002–1.048; p=0.03), but not in multivariable analysis. Effects of temperature measures differed between those who had none vs at least one previous emergency admission: ORs for absolute temperature were 0.970 and 0.988 per 1°C, with ROR 1.018, 95% CI 0.998–1.039, p=0.079. For relative temperature ORs were 1.033 and 1.003, with ROR 0.974, 95% CI 0.951, 0.997, p=0.025, suggesting less impact of relative temperature for those with a previous emergency admission. Conclusion Recommendations for GPs to identify those at highest risk during cold weather cannot be supported by these results.

Can continuity of primary care decrease emergency care use? A nested case-control study

Abstract Background National Health Service emergency departments have been under considerable pressure. Many patients presenting to emergency departments could be managed in primary care, suggesting that aspects of general practice might be associated with unplanned hospital admission. Recently a government scheme introduced the concept of a named GP (general practitioner) responsible for the care of patients aged 75 and older to reduce unplanned hospital admission. We aimed to investigate whether better continuity of care is associated with lower risk of emergency hospital admission. Methods We used records from 10 000 patients aged 65 years and over randomly selected from the Clinical Practice Research Datalink, linked with Hospital Episode Statistics. Using a nested-case control approach, we identified 769 patients with an emergency hospital admission between April 1, 2012, and March 31, 2014, and at least two GP consultations in the previous 2 years, of which the last was within 30 days before hospital admission. 2123 controls were matched on age group, last consultation within the same time-period as the case, and GP practice to account for practice composition, deprivation level, and services such as out-of-hours. For both cases and controls we calculated two longitudinal measures of continuity of care—namely, Bice and Boxermans index, which quantifies the extent to which the patient saw the same GP, and proportion of times seen by an index GP (ie, last GP seen before admission). Conditional logistic regression models were applied to estimate the odds ratio (OR) associated with continuity of care, adjusting for sex, number of consultations, previous hospital admission, and a range of comorbidities. Findings Both the Bice and Boxerman and the appointed index GP measures showed a graded inverse association between lower continuity of care and higher risk of emergency hospital admission (OR for those experiencing the least continuity of care 2·1 [95% CI 1·3–3·2] and 2·3 [1·6–2·9], respectively, compared with those who always saw the same GP). Interpretation Better continuity of care might reduce emergency hospital admission. More research is needed to understand this association including distinguishing between GP-referred emergency hospital admissions and admissions through the emergency department. Such an analysis requires a bigger data set. Funding National Institute for Health Research School of Primary Care Research grant (round 9, project number 246).