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Variation in referral rates to emergency departments and inpatient services from a GP Out Of Hours service and the potential impact of alternative staffing models

Variation in referral rates to emergency departments and inpatient services from a GP Out Of Hours service and the potential impact of alternative staffing models
Variation in referral rates to emergency departments and inpatient services from a GP Out Of Hours service and the potential impact of alternative staffing models
Introduction: out of hours (OOH) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the Emergency Department (ED) and on call specialties.
Methods: we studied the variation in referral rates (to the emergency department and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600,000 people. We calculated the referral probability for each clinician over a 13 month period of practice (1.12.14 – 31.12.2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity.
Results: among the 119,835 contacts with the service, 5,261 (4.4%) were sent directly to the ED and 3,474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they didn’t work in the local practices (5.5% vs 3.5% P = 0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week.
Conclusions: there is substantial variation in clinician referral rates from out of hours primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective.
Urgent care, systems, operational research
2307-1230
784-788
Lasserson, Daniel
cc9c788f-2120-4605-9748-4d326e94bc00
Smith, Honora
1eaef6a6-4b9c-4997-9163-137b956c06b5
Sophie, Garland
26689901-30c4-4f61-b2ad-4bd8c5e50a5a
Hunt, Helen
3be04afa-5fdb-4d23-9239-0d0ee51ae341
Hayward, Gail
f17d89bd-ca37-4ce0-a2cb-48bc8f9245db
Lasserson, Daniel
cc9c788f-2120-4605-9748-4d326e94bc00
Smith, Honora
1eaef6a6-4b9c-4997-9163-137b956c06b5
Sophie, Garland
26689901-30c4-4f61-b2ad-4bd8c5e50a5a
Hunt, Helen
3be04afa-5fdb-4d23-9239-0d0ee51ae341
Hayward, Gail
f17d89bd-ca37-4ce0-a2cb-48bc8f9245db

Lasserson, Daniel, Smith, Honora, Sophie, Garland, Hunt, Helen and Hayward, Gail (2021) Variation in referral rates to emergency departments and inpatient services from a GP Out Of Hours service and the potential impact of alternative staffing models. Emergency Medicine, 38 (10), 784-788, [emermed-2020-209527]. (doi:10.1136/emermed-2020-209527).

Record type: Article

Abstract

Introduction: out of hours (OOH) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the Emergency Department (ED) and on call specialties.
Methods: we studied the variation in referral rates (to the emergency department and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600,000 people. We calculated the referral probability for each clinician over a 13 month period of practice (1.12.14 – 31.12.2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity.
Results: among the 119,835 contacts with the service, 5,261 (4.4%) were sent directly to the ED and 3,474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they didn’t work in the local practices (5.5% vs 3.5% P = 0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week.
Conclusions: there is substantial variation in clinician referral rates from out of hours primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective.

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Accepted/In Press date: 18 January 2021
e-pub ahead of print date: 23 March 2021
Additional Information: Funding This study was not directly funded but HKS was supported by the Economic and Social Research Council (ESRC) Impact Acceleration Account (IAA) at the University of Southampton (grant award number ES/M500458/1). The work was supported by the National Institute for Health Research (NIHR) Community Healthcare MedTech and In Vitro Diagnostic Cooperative (MIC) based at Oxford Health NHS Foundation Trust and by the NIHR Applied Research Collaboration (ARC) West Midlands.
Keywords: Urgent care, systems, operational research

Identifiers

Local EPrints ID: 446356
URI: http://eprints.soton.ac.uk/id/eprint/446356
ISSN: 2307-1230
PURE UUID: 0ba4499e-714b-4c0c-aef1-2ef084803355
ORCID for Honora Smith: ORCID iD orcid.org/0000-0002-4974-3011

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Date deposited: 05 Feb 2021 17:31
Last modified: 24 Nov 2021 02:39

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Contributors

Author: Daniel Lasserson
Author: Honora Smith ORCID iD
Author: Garland Sophie
Author: Helen Hunt
Author: Gail Hayward

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