Effect of patients seeing a general practitioner in accident and emergency on their subsequent reattendance: cohort study

General practitioners working in an accident and emergency department manage non-emergency patients safely and use fewer resources than do usual accident and emergency staff.¹,² In our previous study we speculated that this intervention might have the potential to break the cycle of “inappropriate attendance” at accident and emergency, use of hospital resources, and perceived confirmation of need for a visit.² We now report the results of a review of the reattendance rates of our original study group.

Subjects, methods, and results

The setting and methodology of our original study have been described.² In short, patients who had attended St James's Hospital accident and emergency department between 1 August 1993 and 1 October 1994 were triaged using a validated system into four categories—“life threatening” (1), “urgent” (2), “semi-urgent” (3), and “delay acceptable” (4). Local general practitioners were employed on a sessional basis to manage patients only from categories 3 and 4. Randomisation of patients to general practitioners or usual accident and emergency staff depended on time of registration.

We identified the patients included in our original study and, using their unique identifying numbers, determined the number of times that they had reattended the accident and emergency department within two years of their index visit. The date of each reattendance was not recorded. With this information, we classified patients as reattenders or non-reattenders. Only subsequent visits categorised as 3 or 4 in the triage system were included in this analysis. We excluded visits that patients had been asked to make for the purpose of review, dressings, etc. We assessed the effects of six variables (see table) on reattendance and, using SPSS, performed a direct logistic regression analysis to test the power of these variables to predict reattendance. Socioeconomic status was determined by eligibility for General Medical Services (access to free primary care and drugs). Roughly a third of the Irish population are eligible for General Medical Services and represent the poorest section of the community.

Of the 4684 patients in our original study, 225 could not be identified for inclusion in this study. Of the remaining 4459 patients, 1890 (42%) reattended at least once to the accident and emergency department within two years of their index visit for management of an unrelated complaint (median number of visits 3 (range 1-293, interquartile range 2-5)). The table shows the effects of the study variables on reattendance. Eligibility for General Medical Services, registration with a general practitioner, male sex, and having an index visit categorised as 3 increased the likelihood of reattendance. The median age of those who reattended was 49, not significantly different from the median age of 45 of those who did not reattend (Kruskal-Wallis test). A test of the full model, with all six predictors, against a model with a constant value only was statistically reliable (χ²=164.45 (df=6, n=4356), P<0.01). The model was more effective in predicting those who did not reattend: 74% of non-reattenders and 43% of reattenders were correctly predicted, with an overall success rate of 61%. However, the variance in reattendance accounted for overall was small (Cox and Snell test R²=0.04).

Comment

The decision of patients to attend an accident and emergency department is complex and involves social, psychological, and medical factors.³ Attempts by health services to decrease the numbers of patients attending accident and emergency departments have generally failed.⁴ Our hypothesis that a single contact with a general practitioner working in accident and emergency would have a longlasting effect on health service use has not been supported, although brief, focused interventions by general practitioners have been shown to have lasting effects in other settings.⁵

Table.

Effect of study variables on reattendance of 4459 patients to an accident and emergency department within two years of index visit

Study variable	No (%) of patients who reattended	Relative risk (95% CI) of reattendance
Variables which increased reattendance
Eligible for General Medical Services*:
Yes (n=1683)	896 (53.2)	1.49 (1.39 to 1.59)
No (n=2698)	967 (35.8)	1
Registered with a general practitioner*:
Yes (n=4139)	1767 (42.7)	1.21 (1.03 to 1.41)
No (n=291)	103 (35.4)	1
Sex:
Male (n=2619)	1142 (43.6)	1.09 (1.01 to 1.17)
Female (n=1855)	744 (40.1)	1
Triage category:
Triage 3 (n=3211)	1397 (43.5)	1.13 (1.04 to 1.22)
Triage 4 (n=1263)	489 (38.7)	1
Variables which did not affect reattendance
Type of doctor seen at index visit:
General practitioner (n=2209)	908 (41.1)	0.95 (0.89 to 1.02)
Usual accident and emergency staff (n=2263)	978 (43.2)	1
Any investigation performed at index visit:
Yes (n=2415)	1017 (42.1)	1.0 (0.93 to 1.07)
No (n=2059)	869 (42.2)	1

^*Information was not available for all patients, so total number of patients is <4459.