Predicting clinical deterioration after initial assessment in out-of-hours primary care: a retrospective service evaluation

Hayward, Gail; Vincent, Charles; Lasserson, Daniel

doi:10.3399/bjgp16x687961

Cited by 12 publications

(17 citation statements)

References 10 publications

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“…In the southwest of the UK, referrals to hospital from out-of-hours general practice were 9.2% between 2001 and 2004,15 and 9.5% in 2005/2006 16. In the Oxford area, 8.3% of patients seen in out-of-hours care were referred directly to secondary care 17. These are similar to the 8.5% overall referral rate in this cohort.…”

Section: Discussionsupporting

confidence: 74%

Are referrals to hospital from out-of-hours primary care associated with National Early Warning Scores?

et al. 2020

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BackgroundThe National Early Warning Scores (NEWS) is used in various healthcare settings to augment clinical decision making, and there is growing interest in its application in primary care. This research aimed to determine the distribution of NEWS among patients in UK out-of-hours (OOH) general practice and explore the relationship between NEWS and referral of patients to hospital.MethodsA historical cohort study using routinely collected data from the Birmingham Out-of-hours general practice Research Database. This includes patients who attended a large out-of-hours general practice provider in the West Midlands, UK, between July 2013 and July 2018. All adults who were seen face to face who had a full set of physiological observations recorded were included. NEWS was calculated post hoc, and subsequent hospital referral was the outcome of interest.ResultsA NEWS was calculated for 74 914 consultations. 46.9% of patients had a NEWS of 0, while 30.6% had a NEWS of 1. Patients were referred to hospital in 8.5% of all encounters. Only 6.9% (95% CI 6.3% to 7.5%) of the 6878 patients referred to hospital had a NEWS of ≥5. Of the 1509 patients with a NEWS ≥5, 68.6% (95%CI 66.2% to 70.9%) were not referred to hospital. When considering how NEWS was related to hospital referral, the area under the receiver operating characteristic (AUROC) for patients seen in their own home was 0.731 (95%CI 0.681 to 0.787). For patient seen in treatment centres, the AUROC was 0.589 (95% CI 0.582 to 0.596).ConclusionsPatients seen in out-of-hours general practice have low physiological acuity. Those referred to hospital have a slightly higher NEWS overall. NEWS is poorly associated with hospital referral, although the association is stronger for patients seen in at home compared with patients seen in treatment centres. Implementing NEWS-based referral from OOH general practice is likely to increase hospital admissions.

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Section: Discussionsupporting

confidence: 74%

Are referrals to hospital from out-of-hours primary care associated with National Early Warning Scores?

et al. 2020

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“…Several studies identified characteristics associated with face-to-face contacts, onward referral to ED and subsequent contacts or escalation in care. Analysis of 4 years’ worth of OOHS contacts in one area of England showed that 1% (4832) of all OOHS contacts had a second OOHS contact within 3 days which resulted in referral to urgent secondary care services (eg, hospital admission, ED or immediate ambulance) 67. Increasing age, prior use of OOHS and presentation during periods of low contact rates (eg, overnight) were identified as patient factors associated with this ‘delayed escalation’.…”

Section: Resultsmentioning

confidence: 99%

What do we know about demand, use and outcomes in primary care out-of-hours services? A systematic scoping review of international literature

et al. 2020

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ObjectiveTo synthesise international evidence for demand, use and outcomes of primary care out-of-hours health services (OOHS).DesignSystematic scoping review.Data sourcesCINAHL; Medline; PsyARTICLES; PsycINFO; SocINDEX; and Embase from 1995 to 2019.Study selectionEnglish language studies in UK or similar international settings, focused on services in or directly impacting primary care.Results105 studies included: 54% from mainland Europe/Republic of Ireland; 37% from UK. Most focused on general practitioner-led out-of-hours cooperatives. Evidence for increasing patient demand over time was weak due to data heterogeneity, infrequent reporting of population denominators and little adjustment for population sociodemographics. There was consistent evidence of higher OOHS use in the evening compared with overnight, at weekends and by certain groups (children aged <5, adults aged >65, women, those from socioeconomically deprived areas, with chronic diseases or mental health problems). Contact with OOHS was driven by problems perceived as urgent by patients. Respiratory, musculoskeletal, skin and abdominal symptoms were the most common reasons for contact in adults; fever and gastrointestinal symptoms were the most common in the under-5s. Frequent users of daytime services were also frequent OOHS users; difficulty accessing daytime services was also associated with OOHS use. There is some evidence to suggest that OOHS colocated in emergency departments (ED) can reduce demand in EDs.ConclusionsPolicy changes have impacted on OOHS over the past two decades. While there are generalisable lessons, a lack of comparable data makes it difficult to judge how demand has changed over time. Agreement on collection of OOHS data would allow robust comparisons within and across countries and across new models of care. Future developments in OOHS should also pay more attention to the relationship with daytime primary care and other services.PROSPERO registration numberCRD42015029741.

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“…Gastrointestinal conditions in particular have been highlighted previously as challenging to diagnose in prehospital urgent care settings. 13 14 Evolving OOH care services to include a greater range of point of care (POC) blood and imaging diagnostics and tailored risk scores could offer clinicians support in triaging and managing these difficult presentations.…”

Section: Discussionmentioning

confidence: 99%

What proportion of patients at the end of life contact out-of-hours primary care? A data linkage study in Oxfordshire

et al. 2018

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ObjectivesOut-of-hours (OOH) primary care services are a key element of community care at the end of life, yet there have been no previous attempts to describe the scope of this activity. We aimed to establish the proportion of Oxfordshire patients who were seen by the OOH service within the last 30 days of life, whether they were documented in a palliative phase of care and the demographic and clinical features of these groups.DesignPopulation-based study linking a database of patient contacts with OOH primary care with the register of all deaths within Oxfordshire (600 000 population) during 13 months.SettingOxfordshire.ParticipantsBetween 1 December 2014 and 30 November 2015 there were 102 877 OOH contacts made by 67 943 patients with the OOH service.Main outcome measuresProportion of patients dying in the Oxfordshire population who were seen by the OOH service within the last 30 days of life. Demographic and clinical features of these contacts.Results29.5% of all population deaths were seen by the OOH service in the last 30 days of life. Among the 1530 patients seen, patients whose palliative phase was documented (n=577, 36.4%) were slightly younger (median age=83.5 vs 85.2 years, P<0.001) and were seen closer to death (median days to death=2 vs 8, P<0.001). More were assessed at home (59.8% vs 51.9%, P<0.001) and less were admitted to hospital (2.7% vs 18.0%, P<0.001).ConclusionsOOH services see around one-third of all patients who die in a population. Most patients at the end of life are not documented as palliative by OOH services and are less likely to receive ongoing care at home.

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Predicting clinical deterioration after initial assessment in out-of-hours primary care: a retrospective service evaluation

Abstract: Older, prior users of the service, presenting at less busy times, are at greater risk of requiring secondary care referral from the OOH service within 3 days of their initial contact. These higher-risk patient groups might benefit from active follow-up by the OOH service.

Cited by 12 publications

References 10 publications

Are referrals to hospital from out-of-hours primary care associated with National Early Warning Scores?

Are referrals to hospital from out-of-hours primary care associated with National Early Warning Scores?

What do we know about demand, use and outcomes in primary care out-of-hours services? A systematic scoping review of international literature

What proportion of patients at the end of life contact out-of-hours primary care? A data linkage study in Oxfordshire

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