Access to general practice and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data

The problem

Ahead of the UK general election, both the Conservative and Labour parties have pledged to increase access to general practice. They hypothesise that access frequently influences where patients obtain urgent and emergency care. There is a lack of evidence to support or challenge this hypothesis, and no studies had addressed it in the context of emergency admissions. We had two research questions: (1) Amongst patients in hospital after emergency admission, are those registered to more accessible general practices more likely to have been admitted via a general practitioner (GP) versus via an accident and emergency (A&E) department? (2) Do practice-level rates of emergency admission via a GP and via A&E vary by access to general practice?

The approach

We analysed administrative data (Hospital Episode Statistics) from all non-specialist acute hospitals in England, for 2011-12. The study population consisted of adults admitted in an emergency for ?1 night via a GP or an A&E department (patient-level) and all general practices in England (practice-level). The outcome variables were the route of admission (patient-level) and rates of admission via a given route (practice-level). The measure of access - the percentage of patients able to obtain a general practice appointment on their last attempt - was derived from the GP Patient Survey 2011-12. We estimated the association between these variables, adjusted for patient and population characteristics, using multilevel logistic (patient-level) and negative binomial (practice-level) regression.

Findings

The analysis included 2,322,112 emergency admissions (81.9% via an A&E department). The crude percentages of admissions that were via a GP across five categories of the access measure (<80% of appointment attempts were successful, to ?95% of appointment attempts were successful) were 10.7%, 14.0%, 16.5%, 19.0%, and 21.6%. Using the results of the multilevel logistic regression model, the adjusted mean probabilities of admission via a GP across the five access categories (from the least to most accessible) were 12.8%, 15.0%, 17.0%, 18.4%, and 20.0%. Similar associations were estimated in the subgroup analyses of chronic obstructive pulmonary disease, pneumonia, and urinary tract infections. We will present the corresponding practice-level findings on oral presentation.

Consequences

The results provide the first evidence, internationally, that access to primary care is associated with the setting in which acute care is obtained before admission. The analysis furthers evidence suggesting that access to general practice influences where patients obtain urgent and emergency care, nationally in England. Direct admission via a GP averts A&E use, may reduce total hospital costs, and could improve communication and coordination of care between primary care and hospital services.

Credits

• Thomas Cowling
• Matthew Harris
• Hilary Watt
• Michael Soljak
• Emma Richards
• Elinor Gunning
• Alex Bottle
• Azeem Majeed