Table 2. Capacity Increase in Non-ED Settings.
Author (Year) | Design; Country; Duration of Study | Population | Intervention | Effect on ED Use | Effect on Non-ED Use | Other Outcomes |
---|---|---|---|---|---|---|
Intervention: Additional Clinic(s) | ||||||
Chalder et al. (2003)22 | Matched time-series analysis England One year before and after |
NHS developed walk-in centers with drop-in service Intervention group: 10 towns with walk-in center Control group: 10 similar size towns in same region without walk-in centers |
Walk-in centers provided nurse-led, drop-in service with broad hours of operation | Decrease of 173.3 visits/month vs. decrease of three visits/ month in control group (p = 0.11) | Before and after increase of 3.9 visits to primary care facility vs. 23.7 visits in control group (p = 0.25) | None |
Hsu et al. (2003)24 | Before-and-after observational study with control group England 6 months before and after |
NHS developed walk-in centers with drop-in service Intervention group: one town with walk-in center Control group: one nearby town in the same region without walk-in center |
Walk-in centers provided nurse-led, drop-in service with broad hours of operation | ED visits increased by 10% (adjusted RR = 1.10; 95% CI = 1.00 to 1.21) | 0.10 fewer emergency consultations per day (95% CI = −3.75 to 3.55) | None |
O'Kelly et al. (2010)16 | Retrospective study Ireland 1999–2007 | Single, large ED and out-of-hours general practice emergency service clinic associated with same hospital Intervention group: Dubdoc patients Control group: low-triage-level ED patients |
“Dubdoc” is an out-of-hours general practice emergency services clinic | Significant decrease low-triage-level ED visits during Dubdoc hours (54% decrease in low-acuity ED visits vs. 52% decrease outside Dubdoc hours; p < 0.033) | Increase of 102% in “Dubdoc” visits (3,810 in 1999 to 7,696 in 2007) | Not reported |
Rust et al. (2009)19 | Cohort study United States 2003–2005 | Rural counties in state of Georgia Intervention group: counties with CHCs (n = 24) Control group: counties without federally funded CHCs (n = 93) |
CHCs provide care to the uninsured without medical homes | Non-CHC counties had higher rates of ED visits (RR = 1.21; 95% CI = 1.02 to 1.41) | None reported | None reported |
Intervention: Change in scheduling/hours | ||||||
Hudec et al. (2010)15 | Case-comparison study before-and-after advance access implementation Canada 3 months |
Four family physician practices Intervention group: patients of general practice with advanced access booking Control group: patients of three general practices with traditional booking |
Practice instituted a model in which most appointments are same-day access | 28% reduction in low-acuity ED visits in group | None | 7% revenue increase for practice Improved self-reported patient satisfaction (p < 0.05) |
Philips et al. (2010)23 | Before-and-after observational study with control group Belgium 2006–2007 |
Formation of GPCs Intervention group: city (Turnhout) that implemented GPC Control group: two other large cities that did not have GPC (Ghent and Antwerp) |
GPC reorganized providers for that region and centralized out-of-hours primary health center, open on weekends and holidays | 815 visits to ED before and 791 visits post (no significant change) | Primary care visits increased in the intervention region (714 to 1197 visits) (OR = 1.37; 95% CI = 1.20 to 1.57), while stayed relatively constant in control region (734 to 850 visits) | |
Solberg et al. (2004)20 | Retrospective pre–post study United States 1999–2001 Risk adjusted |
Large, multispecialty medical group Patients with three select chronic conditions (heart disease, diabetes, depression) Intervention group: 17,376 patients in 2001 after implementation of open access Control group: 16,099 patients in 1999 before implementation of open access |
Full advanced access appointments introduced, which included standardization of schedule slots and extra visit time for clinicians | No significant difference in risk-adjusted proportion of patients visiting ED (during this time period, ED visits also increased by 7.8% for the medical group) (all p > 0.05) | Increase in primary care visits (all p < 0.01) Significant decrease in risk-adjusted proportion of patients visiting urgent care (all p < 0.001) |
Total cost per patients increased 10%–20% depending on condition Significant reduction of proportion of patients with hospitalizations (1%) and length of stay >3 days (4%) for heart disease patients only (nonsignificant changes for other conditions) |
Solberg et al. (2006)21 | Retrospective pre–post study United States 1999–2001 Risk adjusted |
Large, multispecialty medical group owned by health plan Intervention group: 6,609 patients with depression in 2001 after implementation of open access Control group: 7,284 patients with depression in 1999 before implementation of open access |
Advanced access appointments instituted (third next-day available appointment reduced from 19.4 to 4.5 days) | No significant change in ED visits | 1% increase in primary care visits (p < 0.01) 2% increase in hospitalizations (p < 0.05) |
17.6% reduction in proportion of patients with no follow-up after starting new medication (p = 0.001) Majority of visits with one physician (continuity of care) increased by 6.7% (p < 0.001) |
van Uden et al. (2004)17 | Retrospective pre–post cohort study Limburg, the Netherlands |
Regional general practitioner cooperatives Intervention group: 12,319 patient contacts after implementation of GPCs Control group: 11,781 patient contacts before implementation of GPCs |
Large cooperatives of general practitioners to offer out of hours primary care, also act as gatekeeper for ED visits | 9% decrease in ED visits after hours 13.7% absolute reduction number of self-referrals to ED |
10% increase in primary care visits after hours 4.6% increase in overall patient contacts after hours 3.6% shift in use from ED to primary care (p < 0.001) |
None |
Wang et al. (2005)18 | Pre–post intervention study with comparison group United States 12 months |
Large, private, primary care pediatric practice with Medicaid patients Intervention group: 17,382 children in the enhanced access program Control group: 26,066 Medicaid-eligible children who received services from other local community primary care providers |
Increased care coordination, case management, expanded after-hours clinics and walk in hours at clinic | 20% reduction in ED utilization for the intervention group (p = 0.007) | Cost per member per month was $8.53 was found in the control group and $7.17 in intervention group, thus a comparative savings of 16% |
CHCs = community health centers; GPCs = group practitioner cooperatives; RR = rate ratio.