Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey

Background

The annual number of unplanned attendances at accident and emergency (A&E) departments in England increased by 11% (2.2 million attendances) between 2008–2009 and 2012–2013. A national review of urgent and emergency care has emphasised the role of access to primary care services in preventing A&E attendances.

Aim

To estimate the number of A&E attendances in England in 2012–2013 that were preceded by the attending patient being unable to obtain an appointment or a convenient appointment at their general practice.

Design and setting

Cross-sectional analysis of a national survey of adults registered with a GP in England.

Method

The number of general practice consultations in England in 2012–2013 was estimated by extrapolating the linear trend of published data for 2000–2001 to 2008–2009. This parameter was multiplied by the ratio of attempts to obtain a general practice appointment that resulted in an A&E attendance to attempts that resulted in a general practice consultation estimated using the GP Patient Survey 2012–2013. A sensitivity analysis varied the number of consultations by ±12% and the ratio by ±25%.

Results

An estimated 5.77 million (99.9% confidence interval = 5.49 to 6.05 million) A&E attendances were preceded by the attending patient being unable to obtain a general practice appointment or a convenient appointment, comprising 26.5% of unplanned A&E attendances in England in 2012–2013. The sensitivity analysis produced values between 17.5% and 37.2% of unplanned A&E attendances.

Conclusion

A large number of A&E attendances are likely to be preceded by unsuccessful attempts to obtain convenient general practice appointments in England each year.     

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.     

Socioeconomic deprivation and accident and emergency attendances: cross-sectional analysis of general practices in England

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.     

Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice

Background

Increasingly, the NHS is embracing the use of digital communication technology for communication between clinicians and patients. Policymakers deem digital clinical communication as presenting a solution to the capacity issues currently faced by general practice. There is some concern that these technologies may exacerbate existing inequalities in accessing health care. It is not known what impact they may have on groups who are already marginalised in their ability to access general practice.

Aim

To assess the potential impact of the availability of digital clinician–patient communication on marginalised groups’ access to general practice in the UK.

Design and setting

Realist review in general practice.

Method

A four-step realist review process was used: to define the scope of the review; to search for and scrutinise evidence; to extract and synthesise evidence; and to develop a narrative, including hypotheses.

Results

Digital communication has the potential to overcome the following barriers for marginalised groups: practical access issues, previous negative experiences with healthcare service/staff, and stigmatising reactions from staff and other patients. It may reduce patient-related barriers by offering anonymity and offers advantages to patients who require an interpreter. It does not impact on inability to communicate with healthcare professionals or on a lack of candidacy. It is likely to work best in the context of a pre-existing clinician–patient relationship.

Conclusion

Digital communication technology offers increased opportunities for marginalised groups to access health care. However, it cannot remove all barriers to care for these groups. It is likely that they will remain disadvantaged relative to other population groups after their introduction.     

Prevalence of comorbid depression and obesity in general practice: a cross-sectional survey

Background

General practice is a common setting for the provision of weight-management advice, as well as the treatment of depression. While there is some evidence of a reciprocal relationship between obesity and depression, there are limited data about the rates of depression among general practice patients who are underweight, normal weight, overweight, and obese.

Aim

To explore the prevalence of depression among underweight, normal weight, overweight, and obese general practice patients.

Design and setting

A cross-sectional survey was conducted in 12 Australian general practices.

Method

Patients aged ≥18 years and older who were presenting for general practice care were eligible to participate. Consenting patients completed a touchscreen computer survey assessing self-reported weight and height. Depression was assessed by the Patient Health Questionnaire-9 (PHQ-9), with a score of ≥10 used to indicate possible depression.

Results

Data were obtained from 3361 participants. The prevalence of depression was 24% (95% confidence interval [CI] = 11.86 to 39.28) among underweight participants, 11% (95% CI = 8.5 to 14.0) among normal weight participants, 12% (95% CI = 0.9 to 15.2) among overweight participants, and 23% (95% CI = 17.8 to 29.0) among obese participants. The prevalence of depression was higher for women than for men across all weight categories except underweight.

Conclusion

Weight and depression demonstrated a U-shaped relationship, with higher prevalence of depression observed among underweight and obese general practice patients. These conditions may act as red flags for opportunistic screening of depression in the general practice setting.     

The Public Health Impact score: a new measure of public health effectiveness for general practices in England

Background

Health policy in the UK is increasingly focused on the measurement of outcomes rather than structures and processes of health care.

Aim

To develop a measure of the effectiveness of primary care in terms of population health outcomes.

Design and setting

A cross-sectional study of general practices in England.

Method

Twenty clinical quality of care indicators for which there was evidence of mortality reduction were identified from the national Quality and Outcomes Framework (QOF) pay-for-performance scheme. The number of lives saved by 8136 English practices (97.97% of all practices) in 2009/2010 was estimated, based on their performance on these measures, and a public health impact measure, the PHI score, was constructed. Multilevel regression models were used to identify practice and population predictors of PHI scores.

Results

The mean estimated PHI score was 258.9 (standard deviation [SD] = 73.3) lives saved per 100 000 registered patients, per annum. This represents 75.7% of the maximum potential PHI score of 340.9 (SD = 91.8). PHI and QOF scores were weakly correlated (Pearson r = 0.28). The most powerful predictors of PHI score were the prevalence of the relevant clinical conditions (β = 0.77) and the proportion of patients aged ≥65 years (β = 0.22). General practices that were less successful at achieving their maximum potential PHI score were those with a lower prevalence of relevant conditions (β = 0.29), larger list sizes (β = −0.16), greater area deprivation (β = −0.15), and a larger proportion of patients aged ≥65 years (β = −0.13).

Conclusion

The PHI score is a potential alternative metric of practice performance, measuring the estimated mortality reduction in the registered population. Rewards under the QOF pay-for-performance scheme are not closely aligned to the public health impact of practices.     

Assessing the appropriateness of information on childhood fever in thermometer package leaflets: a systematic audit of thermometers available in the UK

Background

Thermometers are found in most parents’ homes, but little is known about the quality and accuracy of the information they provide, nor its consistency with current guidelines for managing fever.

Aim

To compare information included with commonly available thermometers with National Institute for Health and Care Excellence (NICE) guidance for management of feverish illness in children.

Design and setting

Systematic thermometer sampling from UK retailers between February 2013 and May 2013.

Method

Information was extracted from device packaging and leaflets on details and type of thermometer, instructions for use, normal ranges, and fever thresholds cited. This was compared with key parental recommendations from the 2013 NICE guidance on feverish illness in children. Associations were explored between cost of device and level of information.

Results

There were 123 thermometers identified (ranging from £0.99 to £69.99), none of which made explicit reference to NICE guidance. Most (n = 81, 65.9%) recommended use at a body site consistent with NICE guidance, but only 17 (13.8%) defined fever using the correct threshold (≥38.0°C), and few (n = 12, 9.8%) included advice on fever management, of which four suggested actions not advised by NICE. There was no association between thermometer cost and provision of information consistent with NICE guidance.

Conclusion

Parents and caregivers have access to a large number of thermometers, yet they lack evidence-based information about fever detection and management, and in some cases contain misleading information. This represents a missed opportunity to disseminate best practices from guidelines for management of fever in children, and thermometer manufacturers are urged to include information consistent with current guidance.     

Children at risk of medicinal and non-medicinal poisoning: a population-based case-control study in general practice

Background

Preschool children have a high risk of poisoning. While medicines prescribed by primary care are potential poisoning agents, the risk factors for poisoning from medication are not well described.

Aim

To identify risk factors for medicinal and non-medicinal poisoning in preschool children.

Design and setting

Population-based nested case-control study using The Health Improvement Network primary care database 1988–2004.

Method

Conditional logistic regression was used to identify child, maternal, and social risk factors for medicinal (1316 cases) and non-medicinal poisoning (503 cases), using 17 709 controls matched on general practice.

Results

Poisoning by medicines was independently associated with deprivation (test for trend P<0.001), maternal age (P<0.001), birth order (P<0.001), maternal alcohol misuse (odds ratio [OR] = 5.44, 95% confidence interval [CI] = 1.99 to 14.91), and perinatal depression (OR = 1.54, 95% CI = 1.26 to 1.88). Living in a household with two or more adults lowered the odds of injury compared to single-parent households (OR = 0.85, 95% CI = 0.74 to 0.96) and the odds varied by age, being highest in 2 year olds (OR = 9.61, 95% CI = 7.73 to 11.95). Non-medicinal poisoning was associated with deprivation (P = 0.001), maternal age (P<0.001), and birth order (P<0.001). The odds were raised in 1 year olds (OR = 5.44, 95% CI = 4.07 to 7.26) and 2 year olds (OR = 5.07, 95% CI = 3.73 to 6.90) compared to those aged <1 year.

Conclusion

Primary care data can be used to target interventions to children at risk of poisoning. This is pertinent when prescribing for children/family members, as prescribed medications may become poisoning agents. Prompt identification of maternal depression and alcohol misuse, and delivery of poisoning-prevention interventions at this stage may help prevent poisonings.     

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.     

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Background

A recent review concluded that general health checks fail to reduce mortality in adults.

Aim

This review focuses on general practice-based health checks and their effects on both surrogate and final outcomes.

Design and setting

Systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Method

Relevant data were extracted from randomised trials comparing the health outcomes of general practice-based health checks versus usual care in middle-aged populations.

Results

Six trials were included. The end-point differences between the intervention and control arms in total cholesterol (TC), systolic and diastolic blood pressure (SBP, DBP), and body mass index (BMI) were −0.13 mmol/l (95% confidence interval [CI] = −0.19 to −0.07), −3.65 mmHg (95% CI = −6.50 to −0.81), −1.79 mmHg (95% CI = −2.93 to −0.64), and −0.45 kg/m² (95% CI = −0.66 to −0.24), respectively. The odds of a patient remaining at ‘high risk’ with elevated TC, SBP, DBP, BMI or continuing smoking were 0.63 (95% CI = 0.50 to 0.79), 0.59 (95% CI = 0.28 to 1.23), 0.63 (95% CI = 0.53 to 0.74), 0.89 (95% CI = 0.81 to 0.98), and 0.91 (95% CI = 0.82 to 1.02), respectively. There was little evidence of a difference in total mortality (OR 1.03, 95% CI = 0.90 to 1.18). Higher CVD mortality was observed in the intervention group (OR 1.30, 95% CI = 1.02 to 1.66).

Conclusion

General practice-based health checks are associated with statistically significant, albeit clinically small, improvements in surrogate outcome control, especially among high-risk patients. Most studies were not originally designed to assess mortality.     

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.     

Caring for people living with,and beyond,cancer: an online survey of GPs in England

Background

Increasing numbers of people are living with, and beyond, cancer. They are at risk of long-term morbidity and premature mortality due to the consequences of their disease and its treatment. Primary care can contribute to providing ongoing care.

Aim

To determine the current practice and views of GPs in England regarding cancer survivorship care.

Design and setting

Online survey of a sample of 500 GPs, stratified by NHS region in England.

Method

The survey included questions adapted from prior surveys assessing physician knowledge and attitudes regarding care of patients with cancer.

Results

In total, 500 GPs responded; approximately half reported often providing care to people living beyond cancer for treatment-related side effects (51%), psychological symptoms (65%), and lifestyle advice (55%). Only 29% felt very confident managing treatment-related side effects compared with 46% and 65% for psychological symptoms and lifestyle advice respectively. Half reported usually receiving cancer treatment summaries and survivorship care plans but most of the sample felt these would improve their ability to provide care (76%). Only 53% were convinced of the usefulness of cancer care reviews. Although most felt that primary and specialist care should share responsibility for managing bone (81%) and cardiovascular (77%) health consequences, fewer than half reported often taking previous history of cancer or cancer treatment into consideration when assessing bone health; only one-fifth did this in relation to cardiovascular health. Most responders were interested in receiving education to improve their knowledge and expertise.

Conclusion

GPs have a potentially important role to play in caring for people following cancer treatment. This study has highlighted areas where further support and education are needed to enable GPs to optimise their role in cancer survivorship care.