General practitioners providing non-urgent care in emergency department : a natural experiment

Objective: To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department (ED) differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators. Design: Propensity score matched cohort study Setting: GPs in A&E co-located within the University Hospitals Coventry and Warwickshire NHS Trust (UHCW) between May 2015 and March 2016. Participants: Non-Urgent Attendances visits to the A&E department. Main outcomes: Process outcomes (any investigation, any blood investigation, any radiological investigation, any intervention, admission and referrals) and A&E Clinical indicators (spent 4 hours plus, left without being seen, and seven-day re-attendance). Results: A total of 5,426 patients seen by GPs in A&E were matched with 10,852 patients seen by emergency physicians (ratio 1:2). Compared with standard care in A&E, GPs in A&E significantly: admitted fewer patients (risk ratio [RR] 0.28, 95% confidence interval [CI] 0.25 to 0.31), referred fewer patients to other specialists (RR 0.31, 95% CI 0.24 to 0.40), ordered fewer radiological investigations (RR 0.38, 95% CI 0.34 to 0.42), ordered fewer blood tests (0.57, 95% CI 0.52 to 0.61), and ordered fewer investigations (0.93, 95% CI 0.90 to 0.96). However, they intervened more, offered more primary care follow up (RR 1.78, 95% CI 1.67 to 1.89), and referred more patients to out-patient and other A&E clinics (RR 2.29, 95% CI 2.10 to 2.49). Patients seen by GPs in A&E were on average less likely to spend four hours plus in A&E (RR 0.37, 95% CI 0.30 to 0.45) compared with standard care in A&E. There was no difference in re-attendance after seven days (RR 0.96, 95% CI 0.84 to 1.09). Conclusion: GPs in A&E tended to manage self-reporting minor cases with fewer resources than standard care in A&E, without increasing re-attendance rates