Studies of process outcomes
| Study details and country | Design | Control | Intervention | Results |
|---|---|---|---|---|
| Dale et al10 England 1995 | Quasi-randomised 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) | Control 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 Ireland 1996 | 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 | N=2381 usual ED care | N=2303 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 England 1996 | Prospective survey Nurse triage of primary care patients using decision tool | N=404 Patients screened as minor/primary care were seen by ED staff | N=566 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 Ireland 1999 | 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 | n=1107 Control ED team: 1 consultant, 2 registrars, 5 SHOs | n=771 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 Sweden 1999 | 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 Netherlands 2003 | Comparison of out-of-hours models in two cities over a 3-week period | Stand-alone EDs and GPCs | Integrated ED and GPC | No 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 Netherlands 2004 | 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 GPC | 4-Week period (2002) after establishment of GPC | 8.9% 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 Netherlands 2005 | 3-Week pre-intervention and post-intervention comparison | Stand-alone ED and GPC during out of hours | Integrated ED and GPC during out of hours | 52% 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 Spain 2005 | Prospective interventional study Adult and paediatric low-acuity patients triaged to fast-track area | N=100 Control: resident ED physicians, 08:00–24:00 | N=100 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 England 2007 | Before and after Random sample over a 2-week period | N=200 8 Traditional/stand-alone EDs | N=200 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 Netherlands 2008 | Controlled before and after | Traditional 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 Netherlands 2010 | Before and after comparative study Self-referrers who attended the ED on weekdays (10:00–17:00) | Control n=832 Seen in usual ED | N=695 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 Australia 2011 | Statistical modelling using Victorian Emergency Minimum Dataset | EDs without co-located GP clinic | EDs with co-located GP clinic | WT 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 Netherlands 2013 | 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 GPC | Co-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 Switzerland 2014 | 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 | HGP 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.