Abstract
Background While the health systems of different countries vary with regard to design (i.e.: universal coverage versus private insurance) and delivery (publicly funded versus for profit and not-for-profit hospitals) globally, health systems are commonly facing an ageing population and growing chronic disease burden together with need to better utilise the existing health workforce. Emergency Departments (EDs) continue to be under pressure and are experiencing greater volumes of patients, along with increasing difficulties meeting targets. It is suggested that a significant proportion of patients presenting to the ED could be instead treated in primary care. In response to this suggestion there has been a rise in popularity for health systems to provide lower cost, more accessible care for diagnosis and treatment of low acuity conditions. Objectives This independent rapid review of literature was undertaken to inform ED strategic decision-making and service design. Data sources Focused searches of databases were performed and supplemented by phrase searching and citation searches of key included studies using bibliographic databases PubMed, Joanna Briggs Institute (JBI), and the Cochrane library. Searches were also performed using Google Scholar and relevant emergency medicine journals between 2012-2020 to supplement previously published literature review. Review methods A review was conducted using data sources for literature that pertained to whether or not the utilisation of a General Practitioner (GP) within an ED or closely located unit has a positive impact on clinical outcomes and resource use as well as whether or not it could provide a cost effective solution to freeing up ED resources to treat more critically unwell patients presenting with an acute medical emergency. An iterative process was used to define the search strategy for the review. Relevant systematic reviews and additional primary research papers were included with a narrative assessment of evidence. Results In total 86 publications were included, of which 19 were literature and systematic reviews. Studies were diverse in their design and methodology. Limitations Overall the evidence base on the clinical effectiveness of alternative primary care and integrated-hospital primary care models is weak with no randomised controlled trial designs and reliance on uncontrolled observational and quasi-experimental before-and-after studies. We found no evidence to support the costs and cost-effectiveness associated with these interventions. The studies identified found that research is focused on process measurement, such as number of attendances, rather than patient outcomes other than satisfaction. Finally, there remains a gap in the evidence of models of urgent care within primary care with specific attention to workforce issues, skills, education and retention. Conclusions This review is an attempt to consolidate the evidence from multiple sources. It has relied on prior evaluation of primary sources by authors who have constructed systematic reviews. The factors influencing demand are generally consistent although the extent to which they influence demand and the way in which they interrelate is likely to be mediated by the peculiar health system arrangements and in particular the financial arrangements. The ED plays a very important role in the acute healthcare system. Its congestion results in significant negative consequences such as delays to timely treatment, increased morbidity and mortality, increased cost and decreased satisfaction. The factors causing congestion are complex but include growing demand, deteriorating system capability and blocked access to suitable locations for ongoing healthcare. The potential solution is the contribution from primary healthcare services to reduce hospital ED utilisation. The literature shows few consistent and conclusive findings, mainly due to the differences in health systems, population health characteristics, and the designed interventions. Primary healthcare needs to be accessible in a timely manner, to have clinical capacity to handle acute health crises for patients, physical capacity to the access of investigation facilities and procedural equipment, and the financial capacity to sustain these services for communities. Future work Priorities for research include comparisons of different systems, rigorous economic evaluations and investigations of patient pathways.
Original language | English |
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Place of Publication | Brisbane, Qld. |
Publisher | Queensland University of Technology |
Number of pages | 55 |
DOIs | |
Publication status | Published - 2020 |
Bibliographical note
@The Author(s) 2020. This work is covered by copyright. Unless the document is being made available under a Creative Commons Licence, you must assume that re-use is limited to personal use and that permission from the copyright owner must be obtained forKeywords
- emergency medicine
- family medicine