“Flawed” data may overestimate GP-type patients in EDs

The method used to calculate how many patients presenting to emergency departments may have been better off seeing a general practitioner consistently overestimates the proportion and should no longer be used for policy decisions, according to a new study.

A team led by University of WA professor of emergency medicine and Fremantle Hospital ED physician Yusuf Nagree compared four methods for calculating low acuity or general practice-type patients who presented to ED.

The methods included one developed by UWA professor Peter Sprivulis, which examines the difference between the discharge rates of self-referred patients and GP-referred patients, as well as the widely used Australasian College for Emergency Medicine method, which considers that any self-referred, non-ambulance patient with a medical consultation time under one hour may have been suitable for a GP.

The team also looked at a discharge diagnosis method originally developed by Kevin Ratcliffe at the Tasmanian Department of Health and Human Services, which uses a list of diagnoses of conditions possibly suitable for GP management, as well as the method used by the Australian Institute of Health and Welfare (AIHW), which uses a methodology to determine which ED attendees were GP-type patients by looking at where ED staff placed them on the Australasian Triage Scale (ATS).

In a paper published in the Medical Journal of Australia today, Professor Nagree and his team found that the AIHW method, which they say is relied upon by governments and other organisations to inform health policy decisions, overestimated general practice-type patient workload in EDs and should no longer be used to guide policy decisions.

They found that the other three methods all showed that 10 to 12 per cent of patients attending tertiary EDs may be low acuity patients who would have been suitable for general practice. The AIHW method, on the other hand, showed that general practice-type patients accounted for about 25 per cent of attendances.

Using three years' worth of data on over 500,000 ED attendances at three tertiary hospitals in Perth, extracted from WA's Emergency Department Information System (EDIS), the researchers found that low acuity attendances were not evenly distributed across the week, with proportionally more patients presenting between 8.00am and 5.00pm during the week, and proportionally fewer overnight.

“This suggests that it is not a lack of general practitioners that drives patients to the ED, as weekday working hours are the time of greatest GP availability,” the authors write.

"After-hours GP clinics, super clinics and polyclinics may fill gaps in medical services but have minimal effects on ED attendances. The impact on the ED from diverting general practice-type patients is low, and inaccurate reporting of the true proportion of these patients results in policy and program initiatives that do not address the real cause of ED overcrowding, which is the lack of available inpatient beds.

"While general practice-type patients may add to waiting room numbers, they do not cause ED overcrowding or ambulance diversion and have little effect on ED workload or waiting times."

They were critical of the use of the ATS scale, saying it was a scale of urgency, not complexity and ignored the fact that a patient can have a low triage scale but need complex care.

“An example is an elderly patient living independently who falls and fractures her forearm,” they write. “She is low in urgency but high in complexity, requiring extended allied health support to ensure safe discharge. Such a patient cannot be easily managed in most GP settings.

“Conversely, some high-urgency patients are low complexity. A young patient with fever and a rash should be seen rapidly to assess for serious illnesses such as meningitis. However, once serious illness is excluded, the patient can usually be discharged. This patient might be equally well managed in a primary care environment by experienced GPs.

“Additionally, the AIHW method includes as general practice-type, patients who have actually been referred to the ED by a GP. Admission as a proxy for complexity is becoming less relevant with admission-avoidance strategies such as home nursing.

"The AIHW methodology overestimated general practice-type patient workload in EDs and should no longer be used to guide policy decisions."

In a statement, Professor Nagree said the study clearly showed the data was flawed. "We need to look at changing the indicator we use,” he said. “The data suggests one thing and sure, we have policy going along with it, but the actual true picture isn't as it seems. We're putting in policies aimed at a non-existent problem."

Posted in Australian eHealth

Comments   

# A/prof Terry Hannan 2013-06-18 14:37
This paper by Professor Nagree can be considered a step in the right direction for more accurate measures of health care. It is now well known that the similar measures used by most national bodies [Case-Mix/DRGs/ Activity Based Funding] are poor measure of health care quality and performance. They do not use the "clinical" data that often determines clinical decision making and subsequent outcomes. Also when they are used for health funding there is evidence that the current measures are inflationary to health care delivery through inappropriate funding. In the study listed here it appears as if the data captured from the Emergency Department Information Systems more closely reflect clinical work flows. An example of this use of clinical data was in the 1990s at Georgetown University where the study looked at the main determinants of LOS in patients with CCF compared to DRGS and the cost of data collection. The most significant determinant for LOS in that study was the Serum Sodium which was standardised, reproducible and must more cost efficient to capture.

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