Table 1

Studies of process outcomes

Study details and countryDesignControlInterventionResults
Dale et al10
419 nurse triage sessions—allocation of patients to either primary care (n=215) or ED sessions (n=204)
(10:00–13:00; 14:00–17:00; 18:00–21:00)
n=2382 managed by ED SHOs
n=557 managed by ED registrars
n=1702 managed by sessional GPs
3 h sessions sampled
ED doctors more likely to order X-rays and to refer (p<0.05)
Investigations for problems unrelated to injuries—40% of primary care, 74.5% ED patients (p<0.001)
Follow-up (3-months) n=1458. 23% contacted own GP at least once for same condition
Patients that had seen a GP in the ED made more visits to own GP, underwent more subsequent investigations and were referred more
Murphy et al12
Randomised controlled trial
All new patients attending with conditions that were classified as semi-urgent or ‘delay acceptable’, when GP available. Sequential self-allocation of patients
usual ED care
3 sessional GPs (two 4 h sessions/week each)
GP investigated fewer patients (relative difference 20%; 95% CI 16% to 25%), referred to other hospital services less (39%; 95% CI 28% to 47%), admitted fewer patients (45%; 95% CI 32% to 56%) and prescribed more often (41%; 95% CI 30% to 54%)
No significant effect for 30-day re-attendances; 17% (95% CI 15.7% to 18.8%) of patients seen by GP. 18% (95% CI 16.3% to 19.5%) of patients seen by an ED clinician
Ward et al13
Prospective survey
Nurse triage of primary care patients using decision tool
Patients screened as minor/primary care were seen by ED staff
Minor/primary care seen by GP weekdays (14:00–17:00; 18:00–21:00)
weekends (10:00–13:00; 14:00–17:00)
ED doctors undertook more investigations (p<0.001)
No significant difference in those requiring advice or prescribed medication
ED doctors more likely to refer to on-call teams (10.6% vs 4.5%; p<0.05), ED review clinic (11.7% vs 5.4%; p<0.05) or outpatient referral (22.3% vs 11.2%; p<0.05)
GPs more likely to advise follow-up with community GP (70.9% vs 55.3%; p<0.05)
Gibney et al11
Randomised controlled trial
Untrained receptionist screening of non-ambulance patients as urgent/non-urgent
Patients randomised when GPs available to ED or GP teams by sequential self-allocation of patients
Control ED team:
1 consultant, 2 registrars, 5 SHOs
Intervention—GP team
3 GPs
GPs prescribed significantly more often (% RD=12 (95% CI 1 to 23)) and referred more patients to hospital (% RD=21 (95% CI 9 to 33))
No difference in investigations ordered. 6 (95% CI 13 to 0)
Krakau and Hassler14
Interventional trial with historical control. The separate weeks sampled. 3806 visits
Comparative attendance data for 19 months pre-intervention and post- intervention
Pre-intervention (1 week)Post-intervention (a GP surgery established in the ED (GP only) (2 weeks)The addition of GPs increased the number of visits to the ED by 27%
Percentage of patients managed in the ED who had primary health care needs increased from 22% (95% CI 19% to 25%) to 33% (95% CI 30% to 37%)
Average WT for patients with urgent or emergent complaints increased from 35 min to 40 min (14%). WT for non-urgent complaints reduced from 50 min to 37 min
Van Uden et al15
Comparison of out-of-hours models in two cities over a 3-week periodStand-alone EDs and GPCsIntegrated ED and GPCNo significant difference between ED contacts/1000 population/year (p=0.184)
Higher GPC contacts/1000/year in co-located setting (p=0.036) with lower ED self-referrals (p<0.001)
Van Uden and Crebolder16
Before and after comparison of out-of-hours use. Unclear if GPC were co-located or adjacent/near to ED.4-Week period (2001) before reorganisation to establish GPC4-Week period (2002) after establishment of GPC8.9% reduction in ED attendances
9.8% increase in primary care attendances and 4.6% increase in over all attendances
During out of hours, 3.6% shift from patients using emergency care to primary care (p=0.001; 95% CI 2.5 to 4.7)
Van Uden et al17
3-Week pre-intervention and post-intervention comparisonStand-alone ED and GPC during out of hoursIntegrated ED and GPC during out of hours52% reduction in ED contacts
25% increase in primary care contacts
3.6% overall increase in patients seeking out-of-hours care (p<0.001 for all measures)
Jiménez et al18
Prospective interventional study
Adult and paediatric low-acuity patients triaged to fast-track area
Control: resident ED physicians, 08:00–24:00
GP resident in fast-track area, 16:00–24:00 substituting for ED resident
Reduction in number of tests ordered (41% less; 95% CI −78 to −5)
Significant reduction in time to be seen (20% less; 95% CI −4 to −5), time to treatment (25% less; 95% CI −49 to −4), length of stay (36% less; 95% CI −53 to −19)
Reduction in patients sent to observation ward (78% less; 95% CI −147 to −12).
Re-attendance rate reduced (75% less; 95% CI −6 to −140)
No difference in referral rate or treatment
Salisbury et al7
Before and after
Random sample over a 2-week period
8 Traditional/stand-alone EDs
8 EDs with co-located walk-in centres
No evidence of any effect on attendance rates, process or outcome of care
The proportion of patients managed within 4 h was 94.8% at both intervention and control sites
Kool et al8
Controlled before and afterTraditional separate primary and emergency care.IEPs
Integrated primary and emergency care
Triage/telephone triage according to protocol by GP assistant. Allocate patients to ED doctor, GP or nurse specialist
Waiting/consultation times decreased from 116 min before the IEPs were established to 102 min (p<0.05)
In control settings, waiting/consultation times increased from 94 min to 2 h (p<0.05)
Proportion of self-referrals decreased from 62% before the IEPs were established to 46% (p<0.05)
In the control settings, the proportion of self-referrals increased from 53% to 58% (p<0.05).
Number of patients visiting the ED in the control settings increased from 3985 to 4321. 10 195 patients visited a GP post before the IEPs were established, 12 940 were seen by a GP, GP assistant or nurse after the IEPs were established
In the control settings, the number of patients visiting a GP post decreased from 14 011 to 12 719
All of these changes in throughput were significant (p<0.05)
Boeke et al19
Before and after comparative study
Self-referrers who attended the ED on weekdays (10:00–17:00)
Control n=832
Seen in usual ED
Allocated to GP (additional resource)
The mean process time in the ED decreased from 93 min to 69 min during the intervention (GP) period (p<0.001)
Mean treatment times decreased from 60 min to 35 min (p<0.001)
The new care method resulted in 13% decrease in additional investigations
48.5% received no treatment compared with 40.5% in the control
17% more were referred to GP for aftercare;17% less referred to an OPD
Sharma and Inder20
Statistical modelling using Victorian Emergency Minimum DatasetEDs without co-located GP clinicEDs with co-located GP clinicWT for emergency (category 2) patients in hospitals with co-located GP clinics was 19% less (1.5 min less at the sample mean) than in hospitals without co-located GP clinics
Thijssen et al9
Observational pre-comparison and post-comparison during out-of-hours periods
Change in triage system and closure of one ED during study period
Stand alone ED and GPCCo-located integrated ED and GPC ECAP (emergency care access point)13% reduction in ED patients
26% increase in regional GPC patients
GP referral (213.4% increase from 10.876% to 34.089%) to service,
Increase in hospital admission (20.2%) and follow up (5.8%) rates after integrated model. (all statistically significant)
Wang et al21
Pre–post comparison of HGP and traditional ED
Patients with no immediate life-saving intervention and no or only one resource needed, routed to the HGP by ED nurse
Traditional ED
451 walk-in patients
342 walk-in patients
HGP staffed by ED resident 09:00–17:00 (weekday). GP 17:00–22:30 (weekday), 10:00–22:30 (weekend)
HGP-shared infrastructure, medical supervision and administration with ED. GP as additional resource Unclear if resident also additional
Additional diagnostics for 70.5% of patients (traditional ED) vs 55.6% (HGP) (ie, GPs and residents together), p<0.001
Median admission to discharge time 120 min (ED) (IQR 80–165) vs 60 min (HGP) (IQR 40–90) (p<0.001)
Adjusted OR for diagnostics 1.86 (95% CI 1.06 to 3.27; p=0.032) for ED doctors vs GPs
Higher specialist consultation for HGP (p<0.001)
  • GP, general practitioner; GPC, GP collaborative; HGP, hospital-integrated general practice; IEP, integrated emergency posts; RD, relative difference; % RD, percentage relative difference; SHO, senior house officer; WT, waiting time.