Determining the true burden of general practice patients in the emergency department: The need for robust methodology

The Australian Institute of Health and Welfare (AIHW) recently reported that 41% of ED attendances were potentially general practice (GP) cases.1 The AIHW purports that all Australasian Triage Scale triage category 4 and 5 patients attending EDs, who are not admitted or conveyed to the ED by ambulance or police, are potentially GP cases. It should be noted that there has been almost no clinical input into the determination of this definition, and no attempt to gain the Australasian College for Emergency Medicine (ACEM) opinion on this definition. The definition was made up by NSW Department of Health Consultants2 without significant clinician input, and has since been widely used without any effort to validate it. We believe that the definition used by AIHW is flawed for a number of reasons. The triage category is an urgency, not a complexity scale.3 A patient can have a low triage category but need complex care. An example is the older patient, who lives independently, sustains a fall and breaks an arm. Such a patient is low urgency but high complexity as an extended consultation with a multidisciplinary team including occupational therapy, physiotherapy and social work will be required to ensure that such a patient can be safely discharged home. Such a patient cannot be easily managed in a general practice environment. The converse is also true with many high urgency patients being of low complexity. For example, a young patient with fever and a rash should be seen quickly to exclude serious illness such as meningococcal septicaemia. However, once this has been excluded, the patient can usually be discharged. This patient might be equally well managed in a general practice environment. Most EDs have admission-avoidance strategies such as home nursing. Therefore, the fact that a patient is discharged does not necessarily indicate low complexity. For example, a patient with acute pyelonephritis can be discharged home with i.v. antibiotics administered by home nursing visits. Such a patient is not low complexity as they will require full medical assessment, admission paperwork, blood tests, i.v. cannulation and i.v. antibiotics, which would be difficult in general practice. Therefore, the use of admission as a marker for complexity has serious limitations. Many attendances fitting the AIHW definition occur overnight, when there is no availability of any other medical service other than in the ED. Therefore, they cannot be regarded as inappropriate as no suitable alternative facility exists. Attempts to staff or maintain late night general practices generally fail, because of lack of patient numbers to maintain a viable practice, security issues and the complex nature of what is seen. The AIHW definition includes patients who have been referred to the ED by their general practitioner (GP), and are thus regarded as non-GP patients by GPs themselves! When this point was raised with the authors of the NSW Health report, they replied that if one similar patient was treated by a GP without referral to an ED, then it must follow that all patients of this type were ‘GP suitable’. This is contradicted by the realities of everyday practice. Attendances to the EDs have increased by 21.2% between 2005/2006 and 2009/2010, an annual rate of 4.9%,1 which is well in excess of population growth.4 Numerous reasons have been postulated for this growth including the ageing population, rising incidence of chronic illness and decreasing availability of general practice consultations, especially urgent and after-hours consultations. This in turn has been used to suggest that overcrowding in EDs is often due to GP-type patients inappropriately attending EDs. This unfortunate myth has been extremely difficult to dispel, and is due to poorly validated definitions of inappropriate attendances.5 The calculation of ED attendees who are suitable for general practice is difficult and experienced researchers have made many attempts to quantify these GP-type patients in EDs. An extensive literature review has recently been published6 and found that the rate of non-urgent ED attendances varied between 4.8% and 90%, thus confirming that there is no easy way of determining the true burden of general practice patients in EDs. There is only one validated method in the Australian literature, which found a much lower rate (15%) of potential GP attendances than the AIHW methodology.7 However, to date no researcher has studied or validated the methodology used by the AIHW. A more robust definition commonly used and accepted by clinicians is that of self-presenting Australasian Triage Scale category 4 and 5 patients discharged within 1 h of being attended to by a doctor. Given that the average general practice consultation is 10–15 min, even this definition will overstate the true burden of potential GP-type attendances. It will also be an overstatement as it includes overnight patients, when the reality is that a general practice service overnight is unlikely to be available for a number of years and EDs will continue to provide all overnight medical care. Like many other Western countries, Australia has severe overcrowding in its EDs8 (personal communication9). Overcrowding occurs when demand for inpatient beds exceeds supply resulting in patients staying in EDs well after their emergency care has been completed. Access block is defined as the percentage of patients requiring an inpatient bed who spend more than 8 h in the ED. The Access Block Point Prevalence Survey8 (personal communication: 2010 Australian Access Block Point Prevalence Study presented by Professor Drew Richardson, ACEM Annual Scientific Meeting, Canberra 2010) conducted on behalf of the ACEM was a longitudinal study of rates of access block. The present study showed that access block has been worsening over a number of years in virtually all States and Territories. Overcrowding has clearly been associated with adverse outcomes and increased mortality.10, 11 Much work has been directed into trying to reduce ED demand as a solution to reducing overcrowding. Strategies include community-based chronic illness programmes, telephone advice lines and hospital substitution programmes.12 Of these, only hospital substitution programmes have good evidence for reduction in hospital admissions. Telephone triage lines do not reduce ED demand.13-15 The inaccurate estimate of GP patients in EDs is of significant concern as it leads to misguided strategies to reduce ED overcrowding that will be doomed to fail. These unhelpful strategies include after-hours general practices located in close proximity to the EDs; after-hours telephone consultations; and GP Superclinics. Such strategies are often well funded and widely promoted as a ‘solution’ to ED overcrowding.16, 17 Unsurprisingly, the same issues are seen in New Zealand.18 As most readers would be aware, the Federal Government funds general practice consultations whereas ED attendances are funded by State Governments. Therefore, political tension exists regarding classification of general practice patients in the ED, with State Governments blaming the Federal Government for not providing sufficient GP consultations (because of a lack of GPs, inadequate consultation rebates or inadequate after-hours loadings). This supposedly explains ED overcrowding and dysfunction. It is in the political interest of State Governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients.5 A key component of the Federal Government's Health Reform agenda is 100% funding of all primary care patients regardless of location of care delivery.19 This means that the Federal Government would reimburse State Governments for patients presenting to the EDs who are classified as requiring general practice services. Under the current system, State Governments fully fund these patients. There is now another incentive for State Governments to overstate the true burden of general practice patients in EDs. Patients attend EDs for multiple reasons20 and the literature clearly shows that after-hours general practice clinics, Superclinics and Polyclinics fill a gap in medical services, but do not take any pressure off EDs21-26 (personal communication9). Multiple studies have demonstrated that low acuity patients in the ED (particularly those discharged home) do not contribute to overcrowding, poor waiting times or ambulance diversion and ramping. It is access block, or the inability to move admitted patients to the ward in a timely manner, that is the predominant factor that causes overcrowding, ambulance diversion, ramping and long waiting times21-28 (personal communication9). Strategies to reduce access block will be the only effective means of reducing overcrowding and improving ED functionality. The inappropriate definition for GP-type patients is not only wrong methodologically, but is highly likely to lead to further misdirected policies and poor outcomes for patients. A robust methodology for determining the true burden of general practice patients in EDs (free from political interference) must be developed to enable implementation of correctly targeted ED overcrowding mitigation strategies. The current GP patient definition used by the AIHW is flawed, likely to perpetuate medical myths and lead to poor policy decisions. There is no doubt that ED overcrowding is a significant problem in Australasia, and the main determinant of overcrowding is the lack of inpatient hospital beds, not excessive GP-type patients. The evidence demonstrates increased mortality and morbidity of patients in overcrowded EDs. Solutions to overcrowding will continue to be delayed by the ongoing use of incorrect data. None declared.