Recorded quality of primary care for osteoarthritis: an observational study

Background

Osteoarthritis is the most common chronic disease in the UK, with greater prevalence in women, older people, and those with poorer socioeconomic status. Effective treatments are available, yet little is known about the quality of primary care for this disabling condition.

Aim

To measure the recorded quality of primary care for osteoarthritis, and assess variavariations by patient and/or practice characteristics.

Design of study

Retrospective observational study.

Setting

Eighteen general practices in England.

Method

Records of 320/393 randomly selected patients with osteoarthritis (response rate 81%) were reviewed. High-quality health care was specified by nine quality indicators. Logistic regression modelling assessed variations in quality by age, sex, deprivation, severity, time since diagnosis, and practice size.

Results

There was substantial variation in the recorded achievement of individual indicators (range 5% to 90%). The percentage of eligible patients whose records show that they received care in the form of information provision ranged from 17% to 30%. For regular assessment indicators the range was 27% to 43%, and for treatment indicators the range was 5% to 90%. Recorded achievement of quality indicators was higher in those with more severe osteoarthritis (odds ratio [OR] 1.38, 95% CI = 1.13 to 1.69) and in older patients (OR 1.14, 95% CI = 1.02 to 1.28). There were no significant variations by deprivation score.

Conclusion

This study has demonstrated the feasibility of using existing robust quality indicators to measure the quality of primary care for osteoarthritis, and has found considerable scope for improvement in the recording of high-quality care. The lack of variation between practices suggests that system-level initiatives may be needed to achieve improvement. One challenge will be to improve care for all, without losing the equitable distribution of care identified.     

Primary care quality indicators for children: measuring quality in UK general practice

Background

Child health care is an important part of the UK general practice workload; in 2009 children aged <15 years accounted for 10.9% of consultations. However, only 1.2% of the UK’s Quality and Outcomes Framework pay-for-performance incentive points relate specifically to children.

Aim

To improve the quality of care provided for children and adolescents by defining a set of quality indicators that reflect evidence-based national guidelines and are feasible to audit using routine computerised clinical records.

Design and setting

Multi-step consensus methodology in UK general practice.

Method

Four-step development process: selection of priority issues (applying nominal group methodology), systematic review of National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) clinical guidelines, translation of guideline recommendations into quality indicators, and assessment of their validity and implementation feasibility (applying consensus methodology used in selecting QOF indicators).

Results

Of the 296 national guidelines published, 48 were potentially relevant to children in primary care, but only 123 of 1863 recommendations (6.6%) met selection criteria for translation into 56 potential quality indicators. A further 13 potential indicators were articulated after review of existing quality indicators and standards. Assessment of the validity and feasibility of implementation of these 69 candidate indicators by a clinical expert group identified 35 with median scores 8 on a 9-point Likert scale. However, only seven of the 35 achieved a GRADE rating >1 (were based on more than expert opinion).

Conclusion

Producing valid primary care quality indicators for children is feasible but difficult. These indicators require piloting before wide adoption but have the potential to raise the standard of primary care for all children.     

Patient-reported areas for quality improvement in general practice: a cross-sectional survey

Background

GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.

Aim

To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.

Design and setting

Cross-sectional survey of patients attending Australian general practice clinics.

Method

Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.

Results

In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).

Conclusion

Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required.     

Association between primary care organisation population size and quality of commissioning in England: an observational study

Background

The ideal population size of healthcare commissioning organisations is not known.

Aim

To investigate whether there is a relationship between the size of commissioning organisations and how well they perform on a range of performance measures.

Design and setting

Cross-sectional, observational study of performance in all 152 primary care trusts (PCTs) in England.

Method

Comparison of PCT size against 36 indicators of commissioning performance, including measures of clinical and preventative effectiveness, patient centredness, access, cost, financial ability, and engagement.

Results

Fourteen of the 36 indicators have an unadjusted relationship (P<0.05) with size of the PCT. With 10 indicators, there was increasing quality with larger size. However, when population factors including deprivation, ethnicity, rurality, and age were included in the analysis, there was no relationship between size and performance for any measure.

Conclusion

There is no evidence to suggest that there is an optimum size for PCT performance. Observed variations in PCT performance with size were explained by the characteristics of the populations they served. These findings suggest that configuration of clinical commissioning groups should be geared towards producing organisations that can function effectively across their key responsibilities, rather than being based on the size of their population alone.     

Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data

Background

In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.

Aim

To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.

Design of the study

Cross-sectional analysis of routine data.

Setting

English general practice in 2005/2006.

Method

QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.

Results

A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA_1C] ≤7.4%, HbA_1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).

Conclusion

Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.     

Views of cancer care reviews in primary care: a qualitative study

Background

The Quality and Outcomes Framework (QOF) provides an incentive for practices to establish a cancer register and conduct a review with cancer patients within 6 months of diagnosis, but implementation is unknown.

Aim

To describe: (1) implementation of the QOF cancer care review; (2) patients'' experiences of primary care over the first 3 years following a cancer diagnosis; (3) patients'' views on optimal care; and (4) the views of primary care professionals regarding their cancer care.

Design of study

Qualitative study using thematic analysis and a framework approach.

Setting

Six general practices in the Thames Valley area.

Method

Semi-structured interviews with cancer patients and focus groups with primary care teams.

Results

Thirty-eight adults with 12 different cancer types were interviewed. Seventy-one primary care team members took part in focus groups. Most cancer care reviews are conducted opportunistically. Thirty-five patients had had a review; only two could recall this. Patients saw acknowledgement of their diagnosis and provision of general support as important and not always adequately provided. An active approach and specific review appointment would legitimise the raising of concerns. Primary care teams considered cancer care to be part of their role. GPs emphasised the importance of being able to respond to individual patients'' needs and closer links with secondary care to facilitate a more involved role.

Conclusion

Patients and primary care teams believe primary care has an important role to play in cancer care. Cancer care reviews in their current format are not helpful, with considerable scope for improving practice in this area. An invitation to attend a specific appointment at the end of active treatment may aid transition from secondary care and improve satisfaction with follow-up in primary care.     

Quality of clinical primary care and targeted incentive payments: an observational study

BACKGROUND: Payments for recorded evidence of quality of clinical care in UK general practices were introduced in 2004. AIM: To examine the relationship between changes in recorded quality of care for four common chronic conditions from, 2003 to 2005, and the payment of incentives. DESIGN OF STUDY: Retrospective observational study comparing incentivised and non-incentivised indicators of quality of care. SETTING: Eighteen general practices in England. METHOD: Medical records were examined for 1156 patients. The percentage of eligible quality indicators achieved for each patient was assessed in 2003 and 2005. Twenty-one quality indicators referred to asthma and hypertension: six subject to and 15 not subject to incentive payments. Another 15 indicators referred to depression and osteoarthritis which were not subject to incentive payments. RESULTS: A significant increase occurred for the six indicators linked to incentive payments: from 75% achieved in 2003 to 91% in 2005 (change = 16%, 95% confidence interval [CI] = 10 to 22%, P <0.01). A significant increase also occurred for 15 other indicators linked to 'incentivised conditions'; 53 to 64% (change = 11%, 95% CI = 6 to 15%, P <0.01). The 'non-incentivised conditions' started at a lower achievement level, and did not increase significantly: 35 to 36% (change = 2%, 95% CI = -1 to 4%, P = 0.19). CONCLUSION: The introduction of financial incentives was associated with substantial apparent quality improvement for incentivised conditions. For non-incentivised conditions, quality did not appear to improve. Patients with non-incentivised conditions may be at risk of poorer quality care.     

Quality of care provided to people with dementia: utilisation and quality of the annual dementia review in general practice

Background

Primary care services are often the main healthcare service for people with dementia; as such, good-quality care at this level is important.

Aim

To measure the quality of care provided to people with dementia in general practice using routinely collected data, and to explore associated patient and practice factors.

Design and setting

Observational, cross-sectional review of medical records from general practices (n = 52) in five primary care trusts.

Method

A total of 994 people with dementia were identified from dementia registers. An unweighted quality-of-care score was constructed using information collected in the annual dementia review, together with pharmacological management of cognitive and non-cognitive symptoms. Multilevel modelling was carried out to identify factors associated with quality-of-care scores.

Results

In total, 599 out of 745 (80%) patients with dementia had received an annual dementia review; however, a social care review or discussion with carers was evident in just 305 (51%) and 367 (61%) of those 599 cases, respectively. Despite high prevalence of vascular disease, over a quarter (n = 259, 26%) of all patients with dementia were prescribed antipsychotics; only 57% (n = 148) of these had undergone medication review in the previous 6 months. Those with vascular dementia who were registered with single-handed practices received poorer quality of care than those registered with practices that had more than one GP.

Conclusion

Although the number of people with dementia with a record of an annual dementia review is high, the quality of these reviews is suboptimal. The quality score developed in this study could be used as one source of data to identify weaknesses in practice activity that need to be corrected, and so would be of value to commissioners and regulators, as well as practices themselves.     

Practice size and service provision in primary care: an observational study

Background

In 2004, primary care payments for basic services and enhanced services were separated. This change has greatly facilitated the evaluation of the breadth and volume of services.

Aim

To determine whether larger practices produce a higher volume and greater diversity of enhanced services.

Design of study

Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000.

Setting

A total of 384 practices in 14 English primary care trusts.

Method

Practice data for all practices were collated for enhanced services, practice size, and deprivation. Diversity and volume of enhanced services were used as dependent variables in a series of multiple regression models to ascertain the effect of practice size, and any relationship with deprivation.

Results

Larger practices provided a greater diversity of services (P = 0.002), although this effect was not present in practices with more than 6330 patients. Practice size seems to influence the volume of enhanced services in general medical services, but this effect disappeared when deprivation was taken into account. Deprivation had a negative influence on the volume of enhanced services provided (P = 0.019). The effect of deprivation on volume persisted in practices with more than 6330 patients.

Conclusion

Current average-sized practices provide similar volume and diversity of enhanced services as those in the largest quartile; therefore, there seems to be little merit in creating ‘supersurgeries’ if the aim is to transfer work from secondary to primary care. There does not seem to be an upper threshold above which practice size creates spare capacity and expertise to deliver a significantly greater volume or more diversity of extra services.     

Correlation between prescribing quality and pharmaceutical costs in English primary care: national cross-sectional analysis

Background

Both pharmaceutical costs and quality-indicator performance vary substantially between general practices, but little is known about the relationship between prescribing costs and quality

Aim

To measure the association between prescribing quality and pharmaceutical costs among English general practices

Design and setting

Cross-sectional observational study using data from the Quality and Outcomes Framework and the Prescribing Analysis and Cost database from all 8409 general practices in England in 2005-2006

Method

Correlation between practice achievement of 26 prescribing quality indicators in eight prescribing areas and related pharmaceutical costs was examined.

Results

There was no significant association between the overall achievement of quality indicators and related pharmaceutical costs (P= 0.399). Mean achievement of quality indicators across all eight prescribing areas was 79.0% (standard deviation 4.4%). There were small positive correlations in five prescribing areas: influenza vaccination, beta blockers, angiotensin converting enzyme inhibitors, lipid lowering, and antiplatelet treatment (all P<0.001). There were small negative correlations in two prescribing areas: hypertension (P<0.001) and smoking cessation (P = 0.018).

Conclusion

Correlations between prescribing quality and pharmaceutical costs were much smallerthan expected; possible explanations forthis include a substantial variation in rates of prescribing outside evidence-based protocols, and use of expensive pharmaceuticals instead of cheaper effective alternatives. There remains considerable scope for some practices to make pharmaceutical cost savings while improving quality performance. The ratio of quality scores to related pharmaceutical costs could be developed into a performance indicator     

Primary care characteristics and population-orientated health care across Europe: an observational study

Background

The number of patients with chronic diseases is increasing which poses a challenge to healthcare organisations. A proactive, structured, and population-orientated approach is needed: the chronic care model (CCM) provides such a framework.

Aim

To assess organisational conditions for providing structured chronic care according to the CCM across different healthcare systems.

Design of study

International observational study.

Setting

A stratified sample of 315 primary care practices in 10 European countries and Israel in 2008 and 2009.

Method

Practice questionnaires and interviews. Outcome measures were mean practice scores on CCM domains per country, as a percentage of the maximum score, and the influence of practice size and urbanisation on these scores.

Results

Practice size showed large differences with the largest practices in Spain, England, Finland, and Israel. These countries, with a strong primary care orientation, had most physicians and staff involved per practice. The CCM domains ‘clinical information systems’ and ‘decision support’ had total practice means of 90%; other domains scored about 50%. Spain and England scored above average on almost all domains. Practice size and urbanisation had little impact.

Conclusion

Characteristics for chronic care delivery differed for most CCM domains. The most common characteristics related to computerisation, providing a good starting point and high potential everywhere. All countries showed room for improvement. Further research should focus on relations between practice characteristics, organisational features, including health system and primary care orientation, and outcomes. Primary care seems suited for chronic care delivery; however, a stronger primary care was associated with better scores.     

The UK pay-for-performance programme in primary care: estimation of population mortality reduction

Background

General practices in the UK contract with the government to receive additional payments for high-quality primary care. Little is known about the resulting impact on population health.

Aim

To estimate the potential reduction in population mortality from implementation of the pay-for-performance contract in England.

Design of study

Cross-sectional and modelling study.

Setting

Primary care in England.

Method

Twenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted for pre-existing trends where data were available.

Results

The 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower–upper estimates 7–16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated, over and above the target, 56 (29–81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment.

Conclusion

The contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered.     

Identifying depression among adolescents using three key questions: a validation study in primary care

Background

Depression in adolescents is a serious psychiatric illness. GPs play an important role in identifying adolescents with depression and those at risk of developing depression. Few validated tools are suitable for identifying adolescent depression in general practice.

Aim

To determine if three verbally asked key questions are valid for identifying depression in adolescents.

Design and setting

A cross-sectional, general practice multicentre, validation study was conducted in Oslo, Norway, and Aarhus, Denmark.

Method

A total of 294 adolescents answered three verbally asked key questions followed by a Composite International Diagnostic Interview (CIDI) for psychiatric diagnosis. Inclusion criteria were age (14–16 years) and fluency in the Norwegian or Danish language. The primary outcome was ROC curve statistics in terms of sensitivity and specificity, predictive values, and likelihood ratios of the three key questions. Secondary outcomes were Loevinger’s H, Cronbach’s α, and prevalence of depression.

Results

The three key questions met the criteria for construct and criterion validity for detecting depression among the adolescents. ROC curve statistics for the three key questions demonstrated an AUC of 0.79 for the answer ‘yes’ to either screening question and of 0.73 for the answer ‘yes’ to the help question. The positive predictive value was 31% and the negative predictive value was 97%.

Conclusion

The three key questions are useful for identifying depression in adolescents in primary health care.     

Nursing consultations and control of diabetes in general practice: a retrospective observational study

Background

Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received.

Aim

To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c).

Design and setting

A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011.

Method

Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors.

Results

The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]).

Conclusion

Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care.     

Confidentiality in the waiting room: an observational study in general practice.

An ethnographic study using overt non-participatory observation was used to investigate confidentiality breaches in 13 GP practice reception and/or waiting areas in Lincolnshire. Staff and patient behaviours were observed for 2 hours. Aspects of management systems and physical environment were also thematically analysed. Forty-four instances occurred where patient-identifiable information was overheard. Of these instances, 22 were initiated by staff, 22 by patients, 33 face-to-face, and 10 from telephone conversations. Breaches included name and address, symptoms, conditions, or test results. Interaction between systems and physical environment in relation to 'attention focus', 'sound' and 'layout', increased the likelihood of breach of confidentiality. Further research on the patient perspective is recommended.     

Developing performance indicators for primary care: Walsall's experience

Background

There has been increasing interest in the development of performance indicators in primary care, especially since the introduction of the Quality and Outcomes Framework (QOF). Public health and primary care trusts collect a range of data from routine or non-routine sources that may be useful for this purpose.

Aim

To assess whether performance against the QOF is a robust measure of practice performance when compared with health-inequality indicators and to contribute to the development of a tool to monitor and improve primary care services.

Design of study

A retrospective cross-sectional study.

Setting

Sixty-three GP practices contracted with Walsall Teaching Primary Care Trust.

Method

Correlation analysis and scatter plots were used to identify possible significant relationships between QOF scores and health-inequality data. The study also utilised confidence limit theory and control chart methodology as tools to identify possible performance outliers.

Results

Little correlation was found between overall QOF score and deprivation score. Uptake of flu immunisation (r² = 0.22) and cervical screening (r² = 0.11) both showed a slight increase with increased QOF score. Benzodiazepine (r² = 0.06) and antibiotic prescribing levels (r² = 0.02) decreased slightly with increased QOF scores, although not significantly. An increase in practice-population deprivation score was correlated with a reduction in cervical screening uptake (r² = 0.27) and an increase in benzodiazepine prescribing (r² = 0.25). Statistically significant relationships were found between the patient: GP ratio and flu immunisation uptake (r² = 0.1) and antibiotic prescribing (r² = 0.1). The majority of GPs found it acceptable to use performance indicator data as part of their annual appraisal.

Conclusion

QOF and health-inequality data can be used together to measure practice performance and to develop tools to help identify areas for performance development and the sharing of best practice.     

The nature of informational continuity of care in general practice

Background

The availability of patient information to practitioners forms the basis of informational continuity of care. Changes in family practice that now encourage multiphysician clinics have meant that informational continuity of care has become crucial because it is likely that a patient will not continuously see the same doctor. Therefore a review of the nature of informational continuity is useful.

Aim

To answer the question ‘How is informational continuity developed in general practice?’.

Design of study

A rigorous systematic review of relevant electronic databases.

Method

Databases were searched for articles answering the research question. Articles focused on family medicine and informational continuity of care were included. Data from reviewed articles were independently extracted and reviewed by two researchers. Conceptual and evidence-based articles were included.

Results

Initially, 193 articles were obtained from all five bibliographic databases; 57 were retained following title and abstract review. Of these, 34 articles were included in the final systematic review. Results show that informational continuity of care is developed using paper/electronic records and remembered information collectively, through a series of doctor–patient consultations over time. Obstacles to its development are practitioners not recording patient information and patients not disclosing important details.

Conclusion

These findings have implications for newer styles of primary care that may have a negative impact in the successful management of chronic illnesses in particular.     

Appropriateness of antidepressant prescribing: an observational study in a Scottish primary-care setting

Background

Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially.

Aim

To assess whether GPs prescribe antidepressants appropriately.

Design of study

Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP.

Setting

Four practices in Grampian, Scotland.

Method

Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed.

Results

A total of 237 (26%) participants had HADS scores indicating ‘possible’ (15%) or ‘probable’ (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for ‘possible’ versus ‘no’ depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for ‘probable’ versus ‘possible’ depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for ‘possible’ versus ‘no’ depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for ‘probable’ versus ‘possible’ was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with ‘probable’ depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression.

Conclusion

There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively.     

Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study

Background

Recent health service policies in the UK have focused on improving primary care access in order to reduce the use of costly emergency department services, even though the relationship between the two is based on weak or little evidence. Research is required to establish whether improving primary care access can influence emergency department attendance.

Aim

To ascertain whether a relationship exists between the degree of access to GP practices and avoidable emergency department attendances in an inner-London primary care trust (PCT).

Design and setting

Observational, cross-sectional ecological study in 68 general practices in Brent Primary Care Trust, north London, UK.

Method

GP practices were used as the unit of analysis and avoidable emergency department attendance as the dependent variable. Routinely collected data from GP practices, Hospital Episode Statistics, and census data for the period covering 2007–2009 were used across three broad domains: GP access characteristics, population characteristics, and health status aggregated to the level of the GP practice. Multiple linear regression was used to ascertain which variables account for the variation in emergency department attendance experienced by patients registered to each GP practice.

Results

None of the GP access variables accounted for the variation in emergency department attendance. The only variable that explained this variance was the Index of Multiple Deprivation (IMD). For every unit increase in IMD score of the GP practice, there would be an increase of 6.13 (95% CI = 4.56, 7.70) per 1000 patients per year in emergency department attendances. This accounted for 47.9% of the variance in emergency department attendances in Brent.

Conclusion

Avoidable emergency department attendance appears to be mostly driven by underlying deprivation rather than by the degree of access to primary care.