Introduction. A new model, an emergency care access point (ECAP) for after-hours emergency care, is emerging in The Netherlands. This study assessed the effect on emergency department (ED) utilization and patient flows. Methods. Routinely recorded clinical ED patient data, covering a six-year period, was collected. Segmented regression analysis was used to analyze after-hours changes over time. Results. 59.182 patients attended the ED before the start of the ECAP and 51.513 patients after, a decrease of 13%. Self-referred ED patients decreased 99.5% (OR 0.003; 95% CI 0.002–0.004). Referred patients increased by 213.4% and ED hospital admissions increased by 20.2%. A planned outpatient follow-up increased by 5.8% (OR 1.968 95% CI 1.870–2.071). The latter changed from fewer contacts to more contacts (OR 1.015 95% CI 1.013–1.017). Consultations at the regional genereral practitioner cooperative (GPC) increased by 26.0% (183.782 versus 232.246). Conclusion. ECAP implementation resulted in a decrease in ED utilization, a near absence of self-referring patients, and a higher probability of hospital admission and clinical follow-up. This suggests either an increase of ED patients with a higher acuity or a lower threshold of admitting referred patients compared to self-referred patients. Overall, increased collaboration with after-hours primary care and emergency care seemed to optimize ED utilization. 1. Introduction Organizing after-hours care is an important challenge in many countries. After-hours care is provided between 5？p.m. and 8？a.m., on weekends and national holidays. In most western countries emergency departments (EDs) are confronted with overcrowding, while general practitioners (GPs) are not all easily accessible, especially after hours. Differences in national healthcare systems have a noticeable effect on redirecting patients to primary care services. In the United States, studies show an increase of 23–27% in ED visits between 1997 and 2008 [1, 2]. Simultaneously, delivering primary care access after hours decreased from 40% of the GPs in 2006 to 29% in 2009 and different models exist [3–5]. In western Europe, the GP plays a significant role in providing after-hours care, with 77% of the GPs in Italy, 89% in the UK, and 97% in The Netherlands providing after-hours arrangements [3]. Across Europe, different models of after-hours primary care exist, varying from local rotation groups to large General Practitioner Cooperatives (GPCs) [6, 7]. Despite good primary care access, high and rising ED visits are also an issue in Europe [8]. In the Dutch
References
[1]
N. Tang, J. Stein, R. Y. Hsia, J. H. Maselli, and R. Gonzales, “Trends and characteristics of US emergency department visits, 1997–2007,” Journal of the American Medical Association, vol. 304, no. 6, pp. 664–670, 2010.
[2]
S. R. Pitts, J. M. Pines, M. T. Handrigan, and A. L. Kellermann, “National trends in Emergency Department Occupancy, 2001–2008: effect of inpatient admissions versus Emergency Department Practise intensity,” Annals of Emergency Medicine, vol. 60, no. 6, pp. 679.e3–686.e3, 2012.
[3]
C. Schoen, R. Osborn, P. T. Huynh, M. Doty, J. Peugh, and K. Zapert, “On the front lines of care: primary care doctors' office systems, experiences, and views in seven countries,” Health Affairs, vol. 25, no. 6, pp. w555–w571, 2006.
[4]
C. Schoen, R. Osborn, M. M. Doty, D. Squires, J. Peugh, and S. Applebaum, “A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences,” Health Affairs, vol. 28, no. 6, pp. 1171–1183, 2009.
[5]
S. A. O'Malley, D. Samuel, A. Bond, and E. Carrier, “After-hours care and its coordination with primary care in the US,” Journal of General Internal Medicine, vol. 27, no. 11, pp. 1406–1415, 2012.
[6]
L. Huibers, P. Giesen, M. Wensing, and R. Grol, “Out-of-hours care in western countries: assessment of different organizational models,” BMC Health Services Research, vol. 9, article 105, 2009.
[7]
R. Grol, P. Giesen, and C. van Uden, “After-hours care in the United Kingdom, Denmark, and the Netherlands: new models,” Health Affairs, vol. 25, no. 6, pp. 1733–1737, 2006.
[8]
A. Majeed, “Redesigning after-hours primary care,” Annals of Internal Medicine, vol. 156, no. 1, part 1, pp. 67–68, 2012.
[9]
P. C. E. Steenwijk, E. G. S. van der Sterren, C. J. van Vugt, and Samenwerking huisartsenposten en spoedeisende hulp (SEH), “Collaboration between GP cooperatives and Emergency Departments,” Report from IQ healthcare in collaboration with The Netherlands GP cooperative Association, 2010.
[10]
W. A. M. H. Thijssen, P. H. J. Giesen, and M. Wensing, “Emergency departments in the Netherlands,” Emergency Medicine Journal, vol. 29, no. 1, pp. 6–9, 2012.
[11]
P. Giesen, M. Smits, L. Huibers, R. Grol, and M. Wensing, “Quality of after-hours primary care in the Netherlands: a narrative review,” Annals of Internal Medicine, vol. 155, no. 2, pp. 108–113, 2011.
[12]
E. P. Moll van Charante, G. ter Riet, and P. Bindels, “Self-referrals to the A&E department during out-of-hours: patients' motives and characteristics,” Patient Education and Counseling, vol. 70, no. 2, pp. 256–265, 2008.
[13]
P. Giesen, E. Franssen, H. Mokkink, W. van den Bosch, A. van Vugt, and R. Grol, “Patient either contacting a general practice cooperative or accident and emergency department out of hours: a comparison,” Emergency Medicine Journal, vol. 23, no. 9, pp. 731–734, 2006.
[14]
R. B. Kool, D. J. Homberg, and H. C. M. Kamphuis, “Towards integration of general practitioner posts and accident and emergency departments: a case study of two integrated emergency posts in the Netherlands,” BMC Health Services Research, vol. 8, article 225, 2008.
[15]
C. J. T. van Uden, R. A. G. Winkens, G. Wesseling, H. F. B. M. Fiolet, O. C. P. van Schayck, and H. F. J. M. Crebolder, “The impact of a primary care physician cooperative on the caseload of an emergency department: the Maastricht integrated out-of-hours service,” Journal of General Internal Medicine, vol. 20, no. 7, pp. 612–617, 2005.
[16]
D. M. Pickin, A. O'Cathain, M. Fall, A. B. Morgan, A. Howe, and J. P. Nicholl, “The impact of a general practice co-operative on accident and emergency services, patient satisfaction and GP satisfaction,” Family Practice, vol. 21, no. 2, pp. 180–182, 2004.
[17]
G. Andersson and I. Karlberg, “Lack of integration, and seasonal variations in demand explained performance problems and waiting times for patients at emergency departments: a 3 years evaluation of the shift of responsibility between primary and secondary care by closure of two acute hospitals,” Health Policy, vol. 55, no. 3, pp. 187–207, 2001.
[18]
C. J. T. van Uden, R. A. G. Winkens, G. J. Wesseling, H. F. J. M. Crebolder, and C. P. van Schayck, “Use of out of hours services: a comparison between two organisations,” Emergency Medicine Journal, vol. 20, no. 2, pp. 184–187, 2003.
[19]
H. Philips, R. Remmen, P. van Royen et al., “What's the effect of the implementation of general practitioner cooperatives on caseload? Prospective intervention study on primary and secondary care,” BMC Health Services Research, vol. 10, article 222, 2010.
[20]
F. D. O'Kelly, C. Teljeur, I. Carter, and P. K. Plunkett, “Impact of a GP cooperative on lower acuity emergency department attendances,” Emergency Medicine Journal, vol. 27, no. 10, pp. 770–773, 2010.
[21]
C. J. T. van Uden and H. F. J. M. Crebolder, “Does setting up out of hours primary care cooperatives outside a hospital reduce demand for emergency care?” Emergency Medicine Journal, vol. 21, no. 6, pp. 722–723, 2004.
[22]
J. D. Schuur and A. K. Venkatesh, “The growing role of Emergency Departments in hospital admissions,” The New England Journal of Medicine, vol. 367, pp. 391–393, 2012.
[23]
L. Huibers, W. Thijssen, J. Koetsenruijter, P. Giesen, R. Grol, and M. Wensing, “GP cooperative and emergency department: an exploration of patient flows,” Journal of Evaluation in Clinical Practice, vol. 19, no. 2, pp. 243–249, 2013.
[24]
D. Margolius and T. Bodenheimer, “Redesigning after-hours primary care,” Annals of Internal Medicine, vol. 155, no. 2, pp. 131–132, 2011.
[25]
M. I. Gaakeer, C. L. van den Brand, and P. Patka, “Emergency medicine in the Netherlands: a short history provides a solid basis for future challenges,” European Journal of Emergency Medicine, vol. 19, no. 3, pp. 131–135, 2012.
