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

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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.

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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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