Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis

Background Increasing demand on emergency healthcare systems has prompted introduction of new healthcare service models including the provision of GP services in or alongside emergency departments. In England this led to a policy proposal and £100million (US$130million) of funding for all emergency departments to have co-located GP services. However, there is a lack of evidence for whether such service models are effective and safe. We examined diagnostic errors reported in patient safety incident reports to develop theories to explain how and why they occurred to inform potential priority areas for improvement and inform qualitative data collection at case study sites to further refine the theories. Methods We used a mixed-methods design using exploratory descriptive analysis to identify the most frequent and harmful sources of diagnostic error and thematic analysis, incorporating realist methodology to refine theories from an earlier rapid realist review, to describe how and why the events occurred and could be mitigated, to inform improvement recommendations. We used two UK data sources: Coroners’ reports to prevent future deaths (30.7.13–14.08.18) and National Reporting and Learning System (NRLS) patient safety incident reports (03.01.05–30.11.15). Results Nine Coroners’ reports (from 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error related to GP services in or alongside emergency departments. Initial theories to describe potential priority areas for improvement included: difficulty identifying appropriate patients for the GP service; under-investigation and misinterpretation of diagnostic tests; and inadequate communication and referral pathways between the emergency and GP services. High-risk presentations included: musculoskeletal injury, chest pain, headache, calf pain and sick children. Conclusion Initial theories include the following topics as potential priority areas for improvement interventions and evaluation to minimise the risk of diagnostic errors when GPs work in or alongside emergency departments: a standardised initial assessment with streaming guidance based on local service provision; clinical decision support for high-risk conditions; and standardised computer systems, communication and referral pathways between emergency and GP services. These theories require refinement and testing with qualitative data collection from case study (hospital) sites.

Investigating the impact of distance on the use of primary care extended hours

IntroductionPoor access to general practice services has been attributed to increasing pressure on the health system more widely and low satisfaction among patients. Recent initiatives in England have sought to expand access by the provision of appointments in the evening and at weekends. Services are provided using a hub model. NHS national targets mandate extended opening hours as a mechanism for increasing access to primary care, based on the assumption that unmet need is caused by a lack of appointments at the right time. However, research has shown that other factors affect access to healthcare and it may not simply be appointment availability that limits an individual's ability to access general practice services. ObjectivesTo determine whether distance and deprivation impact on the uptake of extended hours GP services that use a hub practice model. MethodsWe linked a dataset (N = 25,408) concerning extended access appointments covering 158 general practice surgeries in four Clinical Commissioning Groups (CCGs) to the General Practice Patient Survey (GPPS) survey, deprivation statistics and primary care registration data. We used negative binomial regression to estimate associations between distance and deprivation on the uptake of extended hours GP services in the Greater Manchester City Region. Distance was defined as a straight line between the extended hours provider location and the patient's home practice, the English Indices of Multiple Deprivation were used to determine area deprivation based upon the home practice, and familiarity was defined as whether the patient's home practice provided an extended hours service. ResultsThe number of uses of the extended hours service at a GP practice level was associated with distance. After allowing for distance, the number of uses of the service for hub practices was higher than for non-hub practices. Deprivation was not associated with rates of use. ConclusionThe results indicate geographic inequity in the extended hours service. There may be many patients with unmet need for whom the extension of hours via a hub and spoke model does not address barriers to access. Findings may help to inform the choice of hub practices when designing an extended access service. Providers should consider initiatives to improve access for those patients located in practices furthest away from hub practices. This is particularly of importance in the context of closing health inequality gaps.

Inequalities in access to healthcare by local policy model among newly arrived refugees: evidence from population-based studies in two German states

Background Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) and a tendency towards lower GP (OR=0.61 [0.33-1.16]) and emergency department utilization (OR=0.74 [0.48-1.14]). ASR under the EHC model showed a tendency toward higher specialist unmet needs (OR= 1.89 [0.98-3.64]) and avoidable hospitalizations (OR=1.69 [0.87-3.30]) compared to ASR with regular access. A comparison between EHC and HV showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). Conclusion ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist (and partly also GP) services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Minor differences in unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies.

Using mobile phone apps to deliver rural GP services: a critical review using the walkthrough method (Preprint)

BACKGROUND The widespread use of mobile phones in modern society represents new frontiers for improving access to healthcare. This includes using mobile phone applications (apps) to deliver GP services in rural areas as a means of reducing rural health inequalities. But the wider adoption of app-based GP services relies on understanding how they might intersect with the expectations of care within rural health systems. OBJECTIVE This research aimed to critically review a range of GP-service apps in current use, to explore strengths and challenges for use in a rural health service context. METHODS The sample three GP service apps in the top 100 list in the Medical Category Apps in the Apple store, Australia, June 2020. The Walkthrough Method was applied to extract data and critique the explicit factors such as the app interface elements and implicit factors such as the embedded cultural features related to use for people in rural settings. Findings were compared and contrasted between three researchers and with reference to the broader literature, over the course of 6 months, using critical reflection. RESULTS Apps may increase the availability of GP care; however, use leads to being charged out of pocket costs with not rebates, may not be affordable for all rural patients. They mainly applied fixed appointments that mismatch rural need in a context where patients often present late, with complex multi-morbidities. Apps interfaces have limited tailoring to the cultural dimensions of rural healthcare, nor do they collect information to understand the context of a rural consumer (such as town name, access to a regular GP or hospital). The latter could place patients at risk if emergency follow-up services are needed. Patients generally self-select into use with limited support, potentially leading to inappropriate use especially by rural cohorts with limited health literacy. Although apps claimed to avail most GP services, (70-80% in some cases), it emerges after enrolling in these services, that emergency, complex and serious conditions may be excluded, to avoid taking longer than 15 minutes. Apps may also show limited information about continuity/coordination of care potentially imposing fragmented and low-quality care on rural patients. There is commonly no assurance of rural skills/experience of app-based medical staff despite the wider scope of skills needed to be effective in rural general practice. CONCLUSIONS Service apps may increase the availability of GP services but for engaging and being useful in a rural context, they may require more rural-tailored interfaces, capacity to tailor appointment times and costs to patients with complex needs. They could also aid appropriate use through decision-making tools and setting clearer exclusions up front. Finally, for quality, information about doctors’ rural training/experience and a plan to integrate with in-person rural services, is critical. CLINICALTRIAL not applicable

Association between telehealth use and general practitioner characteristics during COVID-19: findings from a nationally representative survey of Australian doctors

ObjectiveTo investigate factors associated with the use of telehealth by general practitioners (GPs) during COVID-19.DesignA nationally representative longitudinal survey study of Australian doctors analysed using regression analysis.SettingGeneral practice in Australia during the COVID-19 pandemic.Participants448 GPs who completed both the 11th wave (2018–2019) of the Medicine in Australia: Balancing Employment and Life (MABEL) Survey and the MABEL COVID-19 Special Online Survey (May 2020).Outcome measuresProportion of all consultations delivered via telephone (audio) or video (audiovisual); proportion of telehealth consultations delivered via video.Results46.1% of GP services were provided using telehealth in early May 2020, with 6.4% of all telehealth consultations delivered via video. Higher proportions of telehealth consultations were observed in GPs in larger practices compared with solo GPs: between +0.21 (95% CI +0.07 to +0.35) and +0.28 (95% CI +0.13 to +0.44). Greater proportions of telehealth consultations were delivered through video for GPs with appropriate infrastructure and for GPs with more complex patients: +0.10 (95% CI +0.04 to +0.16) and +0.04 (95% CI +0.00 to +0.08), respectively. Lower proportions of telehealth consultations were delivered via video for GPs over 55 years old compared with GPs under 35 years old: between −0.08 (95% CI −0.02 to −0.15) and −0.15 (95% CI −0.07 to −0.22), and for GPs in postcodes with a higher proportion of patients over 65 years old: −0.005 (95% CI −0.001 to -0.008) for each percentage point increase in the population over 65 years old.ConclusionsGP characteristics are strongly associated with patterns of telehealth use in clinical work. Infrastructure support and relative pricing of different consultation modes may be useful policy instruments to encourage GPs to deliver care by the most appropriate method.

Current provision of general practitioner services in or alongside emergency departments in England

BackgroundIn 2017, general practitioners in or alongside the emergency department (GPED), an approach that employs GPs in or alongside the ED to address increasing ED demand, was advocated by the National Health Service in England and supported by capital funding. However, little is known about the models of GPED that have been implemented.MethodsData were collected at two time points: September 2017 and December 2019, on the GPED model in use (if any) at 163/177 (92%) type 1 EDs in England. Models were categorised according to a taxonomy as ‘inside/integrated’, ‘inside/parallel’, ‘outside/onsite’ or ‘outside/offsite’. Multiple data sources used included: on-line surveys, interviews, case study data and publicly available information.ResultsAn increase of EDs using GPED was observed from 81% to 95% over the study period. ‘Inside/parallel’ was the most frequently used model: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The adoption of ‘inside/integrated’ models fell from 26% (38/149) to 9% (15/159). Capital funding was received by 87% (142/163) of the EDs sampled. We identified no significant difference between the GPED model adopted and observable characteristics of EDs of annual attendance, 4-hour wait, rurality and deprivation within the population served.ConclusionThe majority of EDs in England have now adopted GPED. The availability of capital funding to finance structural changes so that separate GP services can be provided may explain the rise in parallel models and the decrease in integrated models. Further research is required to understand the relative effectiveness of the various models of GPED identified.

The Association Between the Perceived Unjust Treatment in Healthcare Settings and the Unmet Need for General Practitioner Services Among People With Foreign Background in Finland

Background: Unjust experiences are relatively common among people with foreign background (PFB) in Finland. Despite universal access to public health care, previous studies have shown inequities in the unmet need for medical care between immigrants and the general population. This study examines the association between unjust treatment in healthcare settings and unmet need for general practitioner (GP) services among PFB. Method: The data for this study were drawn from Survey on work and well-being among people of foreign origin (UTH) (n = 4977, response rate 66%). The respondent characteristics were weighted and summarized, and multivariate logistic regression analyses were performed to assess the adjusted odds ratios (OR) of association between perceived unjust treatment and unmet need for GP services. The analyses were conducted in a four-step process where the first model tested the association between unjust treatment in health care settings and unmet need for GP services, second model adjusted this association by sociodemographic factors, third model was further adjusted by migration related factors, and the fourth model adjusted the previous models even further by health related factors.Results: The results of multivariate regression showed that PFB reporting unjust treatment were also significantly more likely to report an unmet need for GP services. The difference remained significant even after controlling for other tested factors (OR=8.68, 95% CI 6.09-12.36, p<.001). In addition to perceived unjust treatment, only younger age, lower self-rated health and existing long-term illness were significantly associated with unmet need for medical care in the final, fully adjusted model.Conclusions: Thus, perceived unjust treatment in health care settings is significantly associated with unmet need for general practitioner services. Ensuring cultural competence throughout the entire organizational structures creates an environment to promote equal treatment for all clients. The overall costs can be reduced effectively by giving the best possible treatment for all health care users.

Perceived treatment and unmet need for medical care among people of foreign origin in Finland

Background Previous international studies show that perceived unjust treatment is relatively common among people with foreign background (PFB) in medical services. This study examines the association between unjust treatment in medical settings and unmet need for general practitioner's (GP) services among PFB in Finland. Methods The data for this study were drawn from Survey on work and well-being among people of foreign origin (UTH) (N = 5449, response rate 66%), conducted in 2014-2015. Respondent characteristics were weighted and summarized, and multivariable logistic regressions were performed to assess the adjusted odds ratios (OR) of association between self-assessed unjust treatment and unmet need for medical care. The analyses were conducted in a three-step process where the first model tested the association between unjust treatment in medical care settings and unmet need for GP services, second model adjusted this association by sociodemographic factors, and the third model further adjusted the previous models by migration related factors. Results PFB reporting unjust treatment were significantly more likely to experience unmet need for GP services, even after controlling for other tested factors (OR = 8.73, 95% CI 6.18-12.33, p&lt;.001). Besides unjust treatment, only employment status was associated with unmet need for GP services (OR = 1.43, 95% CI 1.08-1.89, p = 0.123) in the final model. Immigration related factors were not associated with unmet need for care in this model. Conclusions Perceived unjust treatment in medical settings is strongly associated with unmet need for GP services. Key messages Cultural sensitive treatment could affect the inequities in unmet need for GP services between PFB and overall population. Ensuring cultural competence throughout organizational structures, and not just for individual employees, could create an environment to promote equal treatment of all clients.