BMJ 1996;312:1135-1142 (4 May)

General practice

Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost

Andrew W Murphy, lecturer,a Gerard Bury, professor,a Patrick K Plunkett, consultant,b David Gibney, research fellow and general practitioner,a Mary Smith, research officer,a Edwina Mullan, research assistant,a Zachary Johnson, public health medicine specialist c

a Department of General Practice, University College Dublin, Coombe Healthcare Centre, Dublin 8, Republic of Ireland, b Department of Accident and Emergency Medicine, St James' Hospital, Dublin 8, Republic of Ireland, c Health Information Unit, Eastern Health Board, Dr Steevens Hospital, Dublin 8, Republic of Ireland

Correspondence to: Dr A W Murphy, Department of General Practice, University College Dublin, Crombe Healthcare Centre, Dublin 8, Republic of Ireland.

Abstract

Objective: To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost.
Design: A randomised controlled trial.
Setting: A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis.
Patients: All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion.
Main outcome measures: Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences.
Results: 4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended. 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were £Ir1427 and £Ir117005 respectively.
Conclusion: General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff.

Key messages

  • Key messages

  • A study extending this innovation shows that the care provided to non-emergency patients by general practitioners working as an integral part of an accident and emergency department also differs substantially from the care provided by the usual staff in terms of process

  • Compared with the usual accident and emer- gency department staff, general practitioners investigate fewer patients, refer to other hospital services less often, more often refer patients back to their own general practitioners for follow up, admit fewer patients, and prescribe more often

  • General practitioners within an accident and emergency department have no apparent effect on reattendance rates to the department within 30 days, patient satisfaction, or health status one month after the initial attendance

  • As yet there are no explanations for these differ- ences, which warrant further research


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