Télécharger le rapport (152 p.) - KCE

KCE reports vol. 19B Urgences 25
Practice-based services : GPs within a practice looking after their own
patients after hours
Practice rotas are small group of GPs (six to eight GPs) providing out of
hours care to their own patients
Primary care centres : patients attending a centre rather than being seen in
their own home or in the emergency department after hours
Telephone triage and advice services are the use of telephone consultations
for primary care patients seeking medical help after hours
Outcomes were divided into the following categories: clinical outcomes, medical
workload, and patient and GP satisfaction. The results indicate that the introduction of a
telephone triage and advice service for after-hours primary medical care may reduce the
immediate medical workload. Deputizing services increase immediate medical workload
because of the low use of telephone advice and the high home visiting rate. Cooperatives,
which use telephone triage and primary care centres have a low home
visiting rate and reduce immediate medical workload. There is little evidence on the
effect of different service models on subsequent medical workload apart from the
finding that GPs working in emergency departments may reduce the subsequent medical
workload. There was very little evidence about the advantages of one service model
compared with another in relation to clinical outcome like e.g. death within 7 days.
There is some evidence that deputizing doctors prescribe less appropriately than
doctors from practice-based or co-operative services, and that GPs prescribe more
appropriately than junior emergency medical staff. Studies consistently showed patient
dissatisfaction with telephone consultations. It was concluded that the rapid growth in
telephone triage and advice services appears to have the advantage of reducing
immediate medical workload through the substitution of telephone consultations for inperson
consultations, and this has the potential to reduce costs. However, this has to
be balanced with the finding of reduced patient satisfaction when in-person
consultations are replaced by telephone consultations. These findings should be borne
in mind by policy makers deciding on the shape of future services.
In a recent observational before and after study in the Netherlands, van Uden et al. 110
investigated whether the reorganisation of out of hours primary care, from practice
rotas to GP cooperatives, changed utilisation of primary and hospital emergency care. A
10% increase was found in patient contacts with out of hours primary care, and a 9%
decrease in patient contacts with out of hours emergency care. The number of self
referrals at the ED was reduced by about 4%. It was concluded that the reorganisation
of out of hours primary care has led to a shift in patient contacts from emergency care
to primary care.
The same authors investigated whether differences in numbers and characteristics of
patients using primary or emergency care may be explained by differences in
organisation of out of hours care 111 . Two different organisations of out of hours care in
two Dutch cities (Heerlen and Maastricht) were investigated. Important differences
between the two organisations are the accessibility and the location of primary care
facility of GPÊs. The results of this study show that the organisation of out of hours care
in Maastricht, where the service is just before the entrance of the emergency
department has optimised the GP's gatekeeper function and thereby led to fewer self
referrals at the ED, compared with Heerlen, where the service is located in the city,
hence apart from the emergency department.
Key messages
Different alternative organisation models to reduce workload of emergency
centres are proposed and put in practice. Six main models of after-hours primary
care services (not mutually exclusive) can be identified. The impact on reducing
workload of emergency departments is not conclusively shown