Abstract
Introduction: Increasing numbers of patients are presenting to the emergency department (ED) for medical treatment, adding to the problem of overcrowding. Suboptimal transitions from the ED to primary care providers (PCP) can result in representations to the ED. It is suspected that having a general practitioner (GP) reduces ED presentations and improves follow up with GPs post ED presentation, thereby reducing representations.Aim: The integrative systematic review aimed to identify the barriers and enablers of effective care transition between the ED and PCP. The cohort study established variables that affect the frequency and nature of ED presentations and assessed the influence of having a GP on this frequency in our region.
Methods: An integrative systematic review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (PROSPERO CRD42022316165). A search strategy was applied to extract articles from CINAHL, MEDLINE, PsycINFO, Scopus, and ProQuest Nursing and Allied Health databases. Articles were assessed using predetermined eligibility criteria. A quality assessment and narrative synthesis was conducted.
A cohort study, reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, included patients presenting over three months in 2022. Descriptive, inferential statistics, and univariate and multivariate truncated Poisson regression models were tested in this doctoral thesis.
Key Results: The integrative systematic literature review included 29 studies. The study designs included four qualitative, three mixed-methods, and 22 quantitative studies. A successful care transition was enhanced by access to insurance, ease of payment methods, effective communication, prior booking of PC appointments, and access to transportation. Many patients experienced financial hardship, influencing GP follow-up after ED discharge.
The cohort included 4,990 patients with 5,880 ED presentations. Twelve percent of the patients did not have a GP. Patients without a GP were more likely to be male, aged between 16 and 45 years, born overseas, be of Indigenous or Torres Strait Islander origin, and live in areas other than inner-regional remoteness areas. Patients with a GP were 1.3 times more likely to make vi
repeat visits to the ED than patients without a GP (IRR 1.3, SE 0.2, p = 0.115). Patients aged 46-60 with a GP were seven times more likely to have multiple ED visits than patients without GPs (IRR 7.0, SE 4.9, p = 0.005). Patients with GPs were 1.9 times more likely to have multiple ED visits in GP trading hours (IRR 1.9, SE 0.5, p = 0.013). Patients with a GP triaged as urgent were 2.2 times as likely to have multiple presentations as patients without a GP (IRR 2.2, SE 1.2, p = 0.135).
Conclusion: The integrative systematic review found that a successful transition between ED and PC was enhanced by access to insurance, ease of payment methods, effective communication, prior booking of PC appointments, and access to transportation. Many patients experienced financial toxicity, and the shortfall between fees charged and rebates provided was found to influence PC follow-up compliance. Patients without a regular PCP faced additional challenges to safe and effective transitions of care. The cohort study found that patients with a GP were more likely to have multiple visits to the ED than patients without a GP. Many of these visits occurred during GP hours, which suggests potential barriers to timely access or affordability of appointments. To reduce unplanned and avoidable ED visits, policymakers and government entities should enable timely, accessible and equitable PC services. Future targeted care transition interventions are needed to address identified barriers to create optimised efficiencies in the healthcare system.
| Date of Award | 2025 |
|---|---|
| Original language | English |
| Supervisor | Catherine PATERSON (Supervisor) & Jennie SCARVELL (Supervisor) |