Primary care professionals providing non‐urgent care in hospital emergency departments

Daniela Gonçalves‐Bradley; Jaspreet K Khangura; Gerd Flodgren; Rafael Perera; Brian H Rowe; Sasha Shepperd

doi:10.1002/14651858.CD002097.pub4

Cochrane Database of Systematic Reviews

Profesionales de atención primaria que prestan servicios no urgentes en servicios hospitalarios de urgencia

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DOI:

https://doi.org/10.1002/14651858.CD002097.pub4 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

13 febrero 2018see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Práctica y organización sanitaria efectivas

Copyright:

Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Contraer

Autores

Daniela Gonçalves‐Bradley

Nuffield Department of Population Health, University of Oxford, Oxford, UK
Jaspreet K Khangura

Correspondencia a: Department of Emergency Medicine, University of Alberta, Edmonton, Canada

[email protected]
Gerd Flodgren

Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
Rafael Perera

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
Brian H Rowe

Department of Emergency Medicine, University of Alberta, Edmonton, Canada
Sasha Shepperd

Nuffield Department of Population Health, University of Oxford, Oxford, UK

Contributions of authors

DGB and JKK screened references, extracted data, rated the certainty of the evidence and wrote the review. GF, RP, BHR, and SS provided feedback and contributed to the completion of the review.

Sources of support

Internal sources

Tier I Canada Research Chair in Evidence‐based Emergency Medicine through the Canadian Institutes of Health Research (CIHR) and the Government of Canada (Ottawa, ON), Canada.

Support provided to BHR to work on this review

External sources

National Institute of Health Research, UK.

Declarations of interest

DGB: none known
JKK: none known
GF: none known
RP: none known
BHR: none known
SS: none known

Acknowledgements

We thank Paul Miller (Information Specialist for the Cochrane Effective Practice and Organisation of Care Group (EPOC)), for his input on the search strategy and for running the searches; Julia Worswick (EPOC's Managing Editor) for her support and feedback during the editorial stages; Luciana Ballini (EPOC's Contact Editor) for her feedback; and Gerrard Abi‐Aad, Lucy Johnson, Nick Mays, and Emilie Roberts, who registered and wrote the original protocol in 2000.

National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Effective Practice and Organisation of Care Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service (NHS), or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2018 Feb 13

Primary care professionals providing non‐urgent care in hospital emergency departments

Review

Daniela Gonçalves‐Bradley, Jaspreet K Khangura, Gerd Flodgren, Rafael Perera, Brian H Rowe, Sasha Shepperd

https://doi.org/10.1002/14651858.CD002097.pub4

2012 Nov 14

Primary care professionals providing non‐urgent care in hospital emergency departments

Review

Jaspreet K Khangura, Gerd Flodgren, Rafael Perera, Brian H Rowe, Sasha Shepperd

https://doi.org/10.1002/14651858.CD002097.pub3

2011 Nov 09

Primary and community health care professionals in hospital emergency departments: effects on process and outcome of care and resources

Protocol

Jaspreet K Khangura, Gerd Flodgren, Rafael Perera, Brian H Rowe, Sasha Shepperd

https://doi.org/10.1002/14651858.CD002097.pub2

2000 Apr 24

Primary and community health care professionals in hospital emergency departments: effects on process and outcome of care and resources

Protocol

Gerrard Abi‐Aad, Lucy Johnson, Nick Mays, Emilie Roberts

https://doi.org/10.1002/14651858.CD002097

Differences between protocol and review

We edited the order and description of the objectives to reflect the original outcomes defined in the protocol (Abi‐Aad 2000). We included non‐randomised trials after discussion amongst the current author team. We added a 'Summary of findings' table and updated the Methods section to comply with current Methodological Expectations of Cochrane Intervention Reviews (MECIR) standards. Gerrard Abi‐Aad, Lucy Johnson, Nick Mays, and Emilie Roberts left the review author team, and Daniela C Gonçalves‐Bradley, Jaspreet K Khangura, Gerd Flodgren, Rafael Perera, Brian H Rowe, and Sasha Shepperd joined the review author team.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 Comparisons of general practitioners versus emergency physicians, outcome: 1.1 Admissions.

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Figure 5

Forest plot of comparison: 1 Comparisons of general practitioners versus emergency physicians, outcome: 1.2 All investigations.

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Figure 6

Forest plot of comparison: 1 Comparisons of general practitioners versus emergency physicians, outcome: 1.3 Laboratory investigations.

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Figure 7

Forest plot of comparison: 1 Comparisons of general practitioners versus emergency physicians, outcome: 1.4 Imaging results.

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Figure 8

Forest plot of comparison: 1 Comparisons of general practitioners versus emergency physicians, outcome: 1.5 Any prescription.

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Figure 9

Forest plot of comparison: 1 Comparisons of general practitioners versus emergency physicians, outcome: 1.6 Referrals.

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Analysis 1.1

Comparison 1 Comparions of general practitioners versus emergency physicians, Outcome 1 Admission to hospital.

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Analysis 1.2

Comparison 1 Comparions of general practitioners versus emergency physicians, Outcome 2 Diagnostic tests: all investigations.

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Analysis 1.3

Comparison 1 Comparions of general practitioners versus emergency physicians, Outcome 3 Diagnostic tests: laboratory investigations.

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Analysis 1.4

Comparison 1 Comparions of general practitioners versus emergency physicians, Outcome 4 Diagnostic tests: imaging results.

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Analysis 1.5

Comparison 1 Comparions of general practitioners versus emergency physicians, Outcome 5 Treatments given: any prescription.

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Analysis 1.6

Comparison 1 Comparions of general practitioners versus emergency physicians, Outcome 6 Consultations or referrals to hospital‐based specialists.

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Summary of findings for the main comparison. Primary care professionals compared with ordinary emergency department physicians for patients with minor injuries and illnesses who attend hospital emergency departments

Primary care professionals compared with ordinary emergency department physicians for patients with minor injuries and illnesses who attend hospital emergency departments
Patient or population: patients with minor injuries and illnesses Settings: hospital emergency departments (Ireland, UK, Australia) Intervention: primary care professionals Comparison: ordinary emergency department physicians
Outcomes	Relative effect	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Time from arrival to clinical assessment and treatment	MD 2.1 minutes (95% CI ‐4.9 to 9.2)	260 (1 study)	⊕⊝⊝⊝^1,2 very low	Expressed in minutes Follow‐up not reported.
Total length of ED stay	MD ‐3.2 minutes (95% CI ‐20.2 to 13.8)	260 (1 study)	⊕⊝⊝⊝^1,2 very low	Expressed in minutes Follow‐up not reported.
Admission to hospital	RR ranged from 0.33 to 1.11	11,203 (3 studies)	⊕⊝⊝⊝ very low^3,4,5	Percentage of patients admitted to hospital from ED Follow‐up: 7 to 15 months
Diagnostic tests	RR ranged from 0.35 to 0.96 (laboratory investigations) RR ranged from 0.47 to 1.07 (imaging results)	11,203 (3 studies)	⊕⊝⊝⊝ very low^1,4,5	Percentage of patients for whom any blood investigation or imaging results were ordered Follow‐up: 7 to 15 months
Treatments given	RR ranged from 0.95 to 1.45 (any prescription)	11,203 (3 studies)	⊕⊝⊝⊝ very low^1,4,5	Percentage of patients given medication or prescription Follow‐up: 7 to 15 months
Consultations or referrals to hospital‐based specialists	RR ranged from 0.5 to 1.21	11,203 (3 studies)	⊕⊝⊝⊝ very low^3,4,5	Percentage of patients referred to consultants Follow‐up: 7 to 15 months In Dale 1995, patients referred to on‐call teams were excluded.
Costs	Cost reduction associated with the intervention ranged from GBP 60,876 to IEP 95,125.	9325 (2 studies)	⊕⊝⊝⊝^4,6 very low	Cost in GBP excludes hospital admissions; it is unclear whether cost in IEP includes or excludes hospital admissions.
Adverse events	‐	‐	‐	We did not find any study reporting on adverse events.
CI: confidence interval; ED: emergency department; MD: mean difference; RR: risk ratio GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹We downgraded the evidence due to indirectness. ²We downgraded the evidence two points due to very serious imprecision (very wide confidence intervals including null‐effect and appreciable benefit or harm). ³We downgraded the evidence due to imprecision (wide confidence intervals including null‐effect and appreciable benefit or harm). ⁴We downgraded the evidence due to trial design (cross‐over of physicians in primary care sessions in Dale 1995 and predictable allocation of patients to either emergency physicians or general practitioners in Murphy 1996 and Gibney 1999). ⁵We downgraded the evidence due to inconsistency. ⁶We downgraded the evidence due to risk of bias.

Summary of findings for the main comparison. Primary care professionals compared with ordinary emergency department physicians for patients with minor injuries and illnesses who attend hospital emergency departments

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Table 1. Results summary

	Dale 1995 (N = 4641)	Murphy 1996 (N = 4684)	Gibney 1999 (N = 1878)
Laboratory investigations ordered	RR 0.22, 95% CI 0.14 to 0.33	RR 0.35, 95% CI 0.29 to 0.42	RR 0.96, 95% CI 0.76 to 1.2
X‐rays ordered	RR 0.47, 95% CI 0.41 to 0.54	RR 0.77, 95% CI 0.72 to 0.83	RR 1.07, 95% CI 0.99 to 1.15
Admissions	RR 0.33, 95% CI 0.19 to 0.58	RR 0.45, 95% CI 0.36 to 0.56	RR 1.11, 95% CI 0.70 to 1.76
Referrals to specialists	RR 0.50, 95% CI 0.39 to 0.63	RR 0.66, 95% CI 0.60 to 0.73	RR 1.21, 95% CI 1.09 to 1.33
Prescriptions	RR 0.95, 95% CI 0.88 to 1.03	RR 1.45, 95% CI 1.35 to 1.56	RR 1.12, 95% CI 1.01 to 1.23
CI: confidence interval; RR: risk ratio

Table 1. Results summary

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Comparison 1. Comparions of general practitioners versus emergency physicians

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Admission to hospital Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Diagnostic tests: all investigations Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Diagnostic tests: laboratory investigations Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Diagnostic tests: imaging results Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Treatments given: any prescription Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6 Consultations or referrals to hospital‐based specialists Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 1. Comparions of general practitioners versus emergency physicians

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