Summary
During a 2-year natural experiment, in which a GP service was co-located in a busy paediatric ED for non-urgent admissions, patients being managed by GPs instead of ED staff resulted in lower treatment costs, fewer hospital admissions, and fewer patients exceeding the 4-hour waiting target; however, those seen by the GP were subject to higher rates of antimicrobial prescribing.
Strengths and limitations
To the best of the authors’ knowledge, the study presented here, conducted among a large and representative ED cohort over a 2-year period, is the first to assess the combined clinical, process-based, and economic impact of introducing a GP service to a paediatric ED in the UK. The authors have made use of a natural experiment and routinely collected data to pragmatically evaluate the impact of GP co-location in one of Europe’s largest and busiest specialist paediatric EDs. Although this was a retrospective observational study, the treatment groups were almost identical in terms of demographics and case mix, which have been previously shown to affect the outcomes under consideration.25 This limited the likelihood of confounding bias, thereby providing generalisable insights regarding the management of non-urgent presentations to EDs. Furthermore, although observational, the approach taken to estimate costs was highly thorough and representative of real-world management, including details such as nursing time required to prepare and provide medications, and clinical time required to order and interpret investigations.
The study presented here does have some limitations. The authors did not collect data on several factors that may have affected both ED and GP staff workload, including: how busy the department was at any given time; the number of staff on shift; and the availability and capacity of connected departments, such as pathology and radiology, which may have affected the ability for GPs and ED clinicians to treat and investigate the children included efficiently. In addition, although every effort was made to eliminate sources of bias, including the large patient numbers and subsequently balanced baseline characteristics, the retrospective nature of the study and lack of randomisation does leave the opportunity for unknown causes of bias that could not be adjusted for.
Higher rates of incomplete data capture and exclusion for the ED group very likely did not impact the findings. These seemed to be missing at random in verification samples; however, the authors can neither confirm this with certainty, nor determine how these patients would have affected the detailed findings of the study.
Finally, the fact that the operational hours of the GP service only covered a third of the operating hours of the ED (2.00 pm-10.00 pm) means that generalisability of the findings could be limited as it cannot be guaranteed that similar patterns of care would be observed overnight when services, diagnostics, and access to radiography are limited.
Comparison with existing literature
Prior interventional analyses and systematic reviews have suggested that the co-location of GPs in EDs may not have a significant impact on reducing the cost of care per patient28,29 but may, in fact, increase costs because of extra personnel.29 However, the findings presented here — in the largest cohort to date of which the authors are aware — suggest otherwise. Despite personnel costs increasing, children requiring non-urgent health care managed by GPs experienced significant reductions in total costs of management, predominantly resulting from reductions in inpatient admission, investigations, and radiography; this has also been observed in similar studies.21,22,30 This difference was most pronounced among younger children (aged <6 months), for whom healthcare costs were reduced by almost 60% and in whom, understandably, ED staff are known to be most cautious.25
In EDs that are frequently overcrowded, the significant reduction in activities associated with waiting (observation, investigations, and radiography) as observed in the GP group, may have a significant effect on patient flow through the ED, resulting in reductions in waiting times and increases in patient satisfaction. This could have major implications for NHS trusts, as breaching the target of resolving at least 95% of the attendances within 4 hours can have serious negative economic consequences for hospitals.31 The increase in achievement of the 4-hour standard from 88.4% in the ED group to 98.6% in the GP group, therefore, also has the potential to save NHS trusts money in the short-to-medium term — possible savings that were not captured in this analysis. However, a potential limitation, observed in both this study and the authors’ previously published pilot study,19 is that a substantial number of patients managed by GPs were subsequently referred to their own GP for further follow-up; this may simply shift some of the burden to primary care. As such, the impact on the whole system of GP in the ED models of care still requires further investigation.
Finally, although GP-led care for non-urgent attendances resulted in several statistically significant benefits, the resulting increase in antibiotic prescription was also statistically significant. There are considerable clinical policy pressures on GPs not to miss sepsis, meningitis, or other illnesses that are serious but rare, often a result of diagnostic uncertainty,25 which may push practitioners to prescribe as a precaution.25,32,33 A previous study found that 44% of GPs might prescribe antibiotics to terminate a consultation;34 implicit in this finding is the potential effect of the increasingly tight time constraints under which GPs work, and the number of children seen over relatively short periods of time. Findings in relation to patients seen by a GP receiving higher rates of microbial prescribing corroborate those of the authors’ previous and much smaller study, which did not include a health economic analysis.19 In the study presented here, children managed by the GP who were seen and discharged within 1 hour were three times more likely to be prescribed antibiotics, compared with children seen and discharged within a similar period who were managed by ED clinicians. Consultation time and GP workload have been shown to be associated with higher antibiotic prescription rates35 and it is worth noting that, in this study, the GP managed almost twice as many non-urgent cases as ED clinicians over the same period. In Norway, a study found that GPs who saw more patients per year prescribed more antibiotics than those with fewer patients;36 this was echoed in a qualitative study of GPs and nurse prescribers in the UK.35
Advances in diagnostic technologies, such as rapid point-of-care (POC) testing, may play a role in reducing unnecessary antibiotic prescribing. POC C-reactive protein testing has been shown to reduce antibiotic prescribing in UK primary care clinics for patients with chronic obstructive pulmonary disease.37 Prior studies have also suggested community antibiotic stewardship by pharmacists,38 and prescribing or social norm feedback as part of continued GP education35,39 or primary care accreditation schemes,40 as means of reducing antimicrobial prescribing. Given the success of these initiatives in reducing antibiotic use in routine practice, coupled with low expected costs of implementation and GPs being easily accessible in a single hospital setting, there is every possibility to reduce antibiotic use.
Implications for research and practice
Given the increasing demands on emergency care, integrative care approaches are a plausible means of increasing capacity and caseload management, particularly given the non-urgent nature of many attendees to the ED. The results of this large-scale natural experiment showed that children seen by a GP in the ED waited less time, had fewer inpatient admissions, and lower costs, but experienced higher antibiotic prescribing than those treated by ED teams. However, further research incorporating causative study designs are required to determine causality between GP management and these outcomes.
