Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors. Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost. Randomized controlled trial of general practitioner versus usual medical care in a suburban accident and emergency department using an informal triage system.
To compare the process and outcome of "primary care" consultations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department.
                Prospective, controlled intervention study.
                A busy, inner city accident and emergency department in south London.
                Patients treated during a stratified random sample of 419 three hour sessions between June 1989 and May 1990 assessed at nurse triage as presenting with problems that could be treated in a primary care setting. 1702 of these patients were treated by sessionally employed local general practitioners, 2382 by senior house officers, and 557 by registrars.
                Process variables: laboratory and radiographic investigations, prescriptions, and referrals; outcome variables: results of investigations.
                Primary care consultations made by accident and emergency medical staff resulted in greater utilisation of investigative, outpatient, and specialist services than those made by general practitioners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house officer v general practitioner consultations and 2.37 (1.84 to 3.06) for registrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v general practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners.
                Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further. To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost.
                A randomised controlled trial.
                A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis.
                All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion.
                Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences.
                4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended, 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were Ir1427 pounds and Ir117,005 pounds respectively.
                General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff. We determined if care provided by general practitioners (GPs) to non-emergency patients, in a suburban accident and emergency (A&E) department using an informal triage system, differs significantly from care provided by usual A&E staff. One thousand eight hundred and seventy-eight patients participated. By comparison with usual A&E staff, GPs prescribed significantly more often (percentage relative difference [% RD] = 12 [95% confidence interval = 1-23]) and referred more patients to hospital (% RD = 21 [95% CI = 9-33]). This is the first study to report that sessional GPs working in an A&E department utilize similar or more resources than usual A&E staff. It emphasizes the need for the continued audit of initiatives that have been introduced into new settings.
Overall, the evidence from the three included studies is weak, as results are disparate and neither safety nor patient outcomes have been examined. There is insufficient evidence upon which to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs versus EPs in the ED to mitigate problems of overcrowding, wait-times and patient flow.