Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices

Abstract

Background: In the UK, the majority of primary care contacts are uncomplicated. However, safety incidents resulting in patient harm occur, such as failure to recognise a patient’s deterioration in health.Aim: We aimed to determine patient and healthcare factors associated with potentially missed deterioration.Design and Setting : A cohort of patients registered with English CPRD general practices between 01-04-2014 and 31-12-2017 with linked hospital data.Methods: We defined a potentially missed deterioration as a patient, seen in primary care by a GP in the three days before hospitalisation, having a self-referred admission. We used generalised estimating equations to investigate factors associated with odds of a self-referred admission. We investigated all diagnoses and subsets of commonly reported missed conditions.Results: There were 116,097 patients who contacted a GP three days prior to an emergency admission. Patients with sepsis or urinary tract infections were more likely to self-refer, adjusted odds ratio 1.10 95%CI(1.02-1.19) and 1.09 (1.04-1.14) respectively. GP appointment durations were associated with self-referral. On average, a 5-minute increase resulted in 10% decrease in odds of self-referred admissions, 0.90 (0.89-0.91). Patients having a telephone (compared with face-to-face) consultation 1.13 (1.09-1.16), previous health service use and health status were also associated with self-referred admission.Conclusions: Differentiating deterioration from self-limiting conditions can be difficult for clinicians, particularly in patients with sepsis, UTI or with long-term conditions. Our findings supports the call for longer GP consultations and cautions reliance on telephone consultations in primary care; however, research is needed to understand the underlying mechanisms.

Frequency and Types of Healthcare Encounters in the Week Preceding a Sepsis Hospitalization: A Systematic Review

“…Two studies were single center while the remaining four included large cohorts of multiple hospitals or national databases. Four studies from the United States evaluated any healthcare encounters available, while two focused on general practitioners and primary care in the Netherlands and United Kingdom healthcare systems, respectively ( 17 , 19 ). A total of 6,785,728 sepsis hospitalizations were evaluated.…”

“…International Classification of Diseases , 9th Revision and 10th Revision codes were primarily used to identify sepsis hospitalizations in all but one of the included studies (17). The timeframe assessed for a healthcare encounter prior to admission was up to 7 days in three of the studies (9, 15, 16), up to 3 days prior to admission in two of the studies (17, 19), and within 1 calendar day in a single study (18). Classification schemes for the healthcare encounters assessed varied across studies but typically included assessment of primary care, specialty care, or ED in some combination (and not always together).…”

“…Liu et al (16) observed primary and specialty care visits as well as ED and urgent care visits. By design, Loots et al (17) only observed encounters in the general practitioner cooperative and Cecil et al (19) only evaluated primary care encounters. The study by Buchman et al (15) categorized visits as office/outpatient versus nursing facility, with established office/outpatient visits of 15 or 25 minutes most commonly billed.…”

“…Electronic database searching yielded 4,985 potential citations. Exclusion criteria were applied as noted in Figure 1 to yield six studies for final inclusion, all published from 2018 to 2021 (9,(15)(16)(17)(18)(19). All six studies were retrospective, observational cohort studies and assessed as low risk of bias for cohort studies (eTable 2, http://links.lww.com/CCX/A914) (9,(15)(16)(17)(18)(19).…”

“…Exclusion criteria were applied as noted in Figure 1 to yield six studies for final inclusion, all published from 2018 to 2021 (9,(15)(16)(17)(18)(19). All six studies were retrospective, observational cohort studies and assessed as low risk of bias for cohort studies (eTable 2, http://links.lww.com/CCX/A914) (9,(15)(16)(17)(18)(19). Two studies were single center while the remaining four included large cohorts of multiple hospitals or national databases.…”