Obesity

2017

Research

General practitioner follow-up in older patients after an emergency department admission

Volume 46, No.7, 2017 Pages 521-526

Belinda Watson

Chun Wah Michael Tam

Belinda Pellizzon

Lucille Ban

Harry Doan

Background

Few studies have investigated older patients with regards to general practice follow-up after an emergency department (ED) admission. We measured the proportion of older patients given explicit general practice follow-up instructions who sought care by day seven after an ED admission.

Methods

Patients discharged from Fairfield Hospital ED (south-western Sydney) who were 65 years and older were approached for a structured telephone interview. Data from the interview and patients’ ED discharge summaries were analysed descriptively. Exploratory statistical analyses were conducted to identify potential explanatory factors.

Results

Fifty patients participated in the study. Most participants (76%) attended general practice follow-up by day seven. Those with more relatives who could be called on for help were more likely to attend the follow-up appointment (P = 0.003). Participants who were not married (54% versus 84%) and non-drivers (53% versus 90%) were less likely to attend for follow-up.

Discussion

Close family support and car transport might influence general practice follow-up in older people. Further exploration of contributing factors may be warranted.

It is well known that Australia has an ageing population. Morbidity and mortality rates increase with ageing1 and increase the burden on the healthcare system. In recent years, emergency department (ED) presentations have increased from 5.7 million in 2008–09 to 6.7 million in 2012–13,2 with older person presentations rising at a rate of 6% annually.3 Those aged 65 years or older are the fastest growing demographic,4 and those aged older than 80 years represent a disproportionately high presentation rate.5

After an ED presentation, many older people will be discharged home for follow-up care with their family doctor in general practice. Effective transition between the different modes of care is imperative, as problems with clinical handover can have a negative impact on patient safety and quality of care.6 This includes increased health risks and re-admissions7,8 in an already at-risk group for ED re-presentation.9

Various factors promote the effective discharge planning of older people as they move from acute to community care. Involvement and education of family members and/or carers, as well as effective interdisciplinary communication between healthcare professionals, including those in general practice, have been found to improve care.8 Discharge communication between EDs and general practice has long been identified as problematic.10 Absent, delayed or inaccurate communication can affect continuity of care and contribute to adverse effects.11 In one survey, almost one-third of  general practitioners (GPs) reported that discharge letters were not received, or that deficiencies in the discharge information was such that the transition process was hindered.12

There is scant literature available on the general practice follow-up behaviour of older people after an ED admission. We sought to investigate this phenomenon in a suburban hospital in south-western Sydney in New South Wales, Australia. 

Methods

The primary aim of this prospective, descriptive study was to measure the proportion of patients aged 65 years and older, discharged from a suburban ED, who had been given explicit general practice follow-up instructions, who then sought care in general practice by day seven after discharge. Potential contributing factors to general practice follow-up, such as social support/isolation and mobility, were also explored.

Research participants were drawn from patients attending the ED of Fairfield Hospital. Over a two-week period in July 2016, patients were advised of the study via ED waiting room posters. The ED staff distributed pamphlets at the time of discharge. Apart from informing patients that a researcher might contact them by telephone, there were no other changes to routine ED care.

Admission and discharge data were reviewed to determine patients who satisfied the inclusion and exclusion criteria. Inclusion criteria were patients who were:

  • aged 65 years or older
  • admitted to the ED during the recruitment weeks
  • subsequently discharged directly back into the community
  • sent with a discharge summary (identified in the ED electronic records system) that included explicit general practice follow-up instructions.

Exclusion criteria were patients who were admitted as inpatients to Fairfield Hospital or transferred to another public health facility prior to discharge.

Prospective participants were contacted by telephone at least seven days after their discharge from the ED and their data collected if they consented to take part in the study. Where a language barrier was encountered at the time of consent, a participant-nominated family member was consented to complete the telephone questionnaire on the participant’s behalf.

Paper forms were used to collect participant data and these were later collated into a spreadsheet. Demographic data were drawn from discharge summaries (ie age, gender, marital status, religion, language spoken at home), as well as details pertaining to the presentation (ie initial complaint, Australian Triage Scale [ATS], time of admission and length of stay, level of healthcare worker responsible for data entry, specifics of follow-up instructions). The road distances between the participants’ home address and Fairfield Hospital and listed general practice address were computed. Further data were collected during the structured telephone interview:

General practice follow-up

  • Did the patient recall receiving a discharge summary when leaving the hospital?
  • Did the patient present to a GP and, if so, when did they present and was this GP the discharge summary addressee?
  • Had they seen a doctor other than a GP?
  • Mobility
  • Did they have access to a car and, if so, did they drive themselves or were they driven by someone else?
  • Do they use mobility aids (eg walking stick, frame)?

Social support

The validated six-question Lubben Social Network Scale (LSNS-6), a self-reported measure of social support/isolation tool, was administered (Table 1)13 – social support is related to health-seeking decisions, and close networks associated with a reduced likelihood of attending EDs unnecessarily.14

Table 1 – Lubben Social Network Scale (LSNS-6)13

Family: Considering the people to whom you are related by birth, marriage, adoption, etc

  1. How many relatives do you see or hear from at least once a month?
  2. How many relatives do you feel at ease with that you can talk about private matters?
  3. How many relatives do you feel close to such that you could call on them for help?

Friendships: Considering all of your friends, including those who live in your neighbourhood

  1. How many of your friends do you see or hear from at least once a month?
  2. How many friends do you feel at ease with that you can talk about private matters?
  3. How many friends do you feel close to such that you could call on them for help?

Scoring: 0, none; 1, one; 2, two; 3, three or four; 4, five to eight; 5, nine or more

Analyses

Data were analysed using Microsoft Excel and IBM SPSS 23. Participants’ demographics were analysed using descriptive statistics. The data were further explored using independent samples t-test, Mann-Whitney U test and chi-squared test, to examine the effect of continuous, ordinal, and categorical variables respectively, on seven-day general practice follow up. These exploratory analyses were used to identify potential explanatory factors and further hypotheses.

Ethics approval

Ethical approval for the study was obtained from the South Western Sydney Local Health District’s Research and Ethics Office (reference number: HE16/066 LNR).

Results

Patient population

A total of 70 people satisfied the inclusion criteria. They were contacted via telephone at least seven days after their ED discharge date for possible participation. Of these, 17 could not be contacted by telephone and three were unable to participate because of difficulties with language, leaving 50 participants who were included in the study.

Participant demographics

The majority of the 50 participants were women (60%) and married (74%), with a mean age of 75.3 years. English was the most common individual language spoken, although more than half of the participants (58%) used another language as their primary language – Assyrian, Italian, Arabic, and Spanish in order of frequency. One-fifth of telephone questionnaires were conducted with a nominated family member.

Most participants were either ATS 3 (36%) or ATS 4 (54%), and generally presented during the day between 6.00 am and 6.00 pm (72%). On the LSNS-6, 20% of participants were scored as ‘socially isolated’, defined as a score of less than 12.13 The mean self-reported satisfaction rating for the ED visit was high (8.2/10; Table 2).

General practice follow-up by day seven after ED discharge

Most participants (76%) attended a general practice by day seven after discharge; day three was the median follow-up day (Figure 1). Of those participants, 18% consulted a GP who was not the addressee in the discharge summary. Almost all participants stated that they received a printed discharge summary on leaving the Fairfield Hospital ED (96%).

AFPJULY2017 Research GP Follow Up Figure 1

Figure 1. Cumulative proportion of study participants who attended general practice follow up after emergency department discharge (days 0–7)


General practice follow-up by day seven – Exploratory analyses

The most statistically significant effect found associated with seven-day general practice follow-up was to Question 3 in the LSNS-6: ‘How many relatives do you feel close to such that you can call on them for help?’ (Table 3). Participants who

attended general practice follow-up by day seven reported a higher score (more relatives that can be called on to help) on this item (P = 0.003).

The participants in this study who had not seen a GP by day seven after discharge seemed more likely to have been female, unmarried/widowed, did not drive, took more regular medications and spent longer in the ED (Table 3).

Discussion

This project measured the proportion of older patients with explicit general practice follow-up instructions who sought care by day seven after ED discharge. While larger studies have addressed why these presentations initially occur,14 we believe that this is the first study of its kind to specifically quantify general practice follow-up behaviour of older people.

In our study, most older patients consulted with a GP in a timely manner. A small number consulted a GP on the day of discharge, a fifth by the next day, and half by day three. This is encouraging from the perspective of continuity of care, and identifies the imperative of discharge summary availability.

Almost all participants in this study stated they were supplied with a printed copy of their discharge summary. Earlier Australian research identified that GPs only receive a quarter of discharge summaries for older people when they were given to patients for hand delivery.15 Direct transmission (eg secure messaging, facsimile) increases the proportion of discharge summaries received.15 However, this study demonstrates a potential upper boundary to the effectiveness of that strategy – a fifth of our participants saw a GP who was not the nominal addressee of the discharge summary.

This finding suggests that any single method of hospital discharge communication is unlikely to be effective. Importantly, where clinical transitions have been suboptimally managed, preventable hospital visits, and even increases in mortality, can occur.16 Looking forward, routinely uploading discharge summaries into the online ‘My Health Record’ (formerly the Australian ‘Personally Controlled Electronic Health Record’) may be the long-term communication solution, assuming there is near universal uptake by the Australian community and health providers. In the present day, however, EDs may need to continue transmitting discharge summaries using multiple methods.

The exploratory analyses conducted were designed to identify potential explanations of the results. Some intriguing associations identified include those between gender, marital and driving status, and general practice follow-up. In this study, women were less likely to be married (more likely to have been widowed), and less likely to drive. Those who were not married and did not drive were less likely to attend for follow-up with their GP. Not surprisingly in this context, the women observed in this study were less likely to attend for follow-up. Transportation barriers are more likely to affect women than men.17 This is a potential identifiable at-risk population regarding their ability to access care, and further research seems warranted.

Another association worthy of further investigation involves individuals who may have been more ill. Worryingly, participants who took a larger number of regular medications and had a longer ED admission were seemingly less likely to have attended general practice follow-up by day seven.

Social isolation as measured by the LSNS-6 score did not seem to be associated with general practice follow-up. Curiously, one question seemed especially important, ‘How many relatives do you feel close to such that you can call on them for help?’, where a low score is associated with a lower likelihood of general practice follow-up. Others have found that social isolation per se may not affect general practice use;18 however, early and active family involvement in discharge planning can assist frail, older patients in the successful transfer from hospital to community care.8 This finding may reflect familial involvement in the discharge process, especially given the acute setting, and the cultural context in which the study took place, with most participants from non–English speaking backgrounds.

Table 2. Participant demographics

Total number of participants = 50

 

General demographics

 

Sex

n (%)

Male

20 (40.0)

Female

30 (60.0)

Age, years  75.3 (65.0–91.0; 7.7)*

 

Marital status

n (%)

Yes

37 (74.0)

No or widowed

13 (26.0)

English primary language

n (%)

Yes

21 (42.0)

No

29 (58.0)

Questionnaire conducted with a family member

n (%)

Yes

10 (20.0)

No

40 (80.0)

Number regular medications

4.7 (3.1)

ED presentation

 

Australian Triage Scale

n (%)

1

0 (0.0)

2

3 (6.0)

3

18 (36.0)

4

27 (54.0)

5

2 (4.0)

Time in minutes spent in ED

214 (98)

ED satisfaction rating

8.2 (1.7)

Kilometres from home to ED

4.8 (4.3)

Kilometres from home to GP

3.8 (3.3)

Mobility and transport

 

Uses aid§

n (%)

Yes

23 (46.0)

No

27 (54.0)

Drives a car

n (%)

Yes

29 (58.0)

No

21 (42.0)

Owns a car

n (%)

Yes

27 (54.0)

No

23 (46.0)

Access to a driver

n (%)

Yes

48 (96.0)

No

2 (4.0)

Social isolation

 

LSNS-6 score

 

Median (range)

15 (7–28)

Interquartile range

9

Socially isolatedǁ, n (%)

10 (20)

*Mean (range; SD); mean (SD); score out of 10;

  • walking stick, frame or wheelchair; ǁscore <12

ED, emergency department; GP, general practitioner; LSNS-6, Lubben-6 Social Network Scale

Strengths and limitations

The main strengths of this study lie in its design. Being prospective in nature, we attempted to recruit all eligible participants over the recruitment period, and the majority of eligible participants (50/70) were included. As data were collected directly from participants or participant‑nominated family members, we are confident of the accuracy of the primary outcome (proportion of people who attended follow-up with their GP).

There are limitations associated with this small study. It was conducted at a single location in an ethnically diverse area of Sydney. It is possible that this is a unique study population that may not reflect broader Australia. Extrapolation of the seven-day general practice follow-up finding to other sites should be made cautiously. Language difficulties were also encountered. Interviews were sometimes conducted with a nominated family member, translating or answering on the participant’s behalf. Use of formal health translators would have been preferable, but this resource was not available. This introduces a source of bias, particularly in the LSNS-6, where the questions are somewhat subjective.

Importantly, the explanatory analyses were designed to be exploratory in nature and should only be seen as hypothesis-generating, given the small study numbers and low statistical power. A limitation of structured questionnaires with forced-choice options is that we cannot be certain about how participants interpreted some questions or the reasons that underlie the responses. Further investigation on this topic could involve replicating the project at more sites. Qualitative research of participants’ perspectives may illuminate the barriers and facilitators to general practice follow up after an ED visit.

Table 3. Associations between general practice follow-up and other factors

Participant characteristics

General practice follow-up by day seven after discharge

Significance*

 

 

 

 

Yes

No

 

Sex

Male (%)

90

10

P = 0.091

 

Female (%)

67

33

Age

Mean years (SD)

74.3 (7.0)

78.3 (9.0)

P = 0.176

Married or regular partner

Yes (%)

84

16

P = 0.055

No (%)

54

46

English primary language

Yes (%)

86

14

P = 0.311

No (%)

71

29

Number of regular medications

Mean (SD)

4.1 (3.1)

6.4 (2.3)

P = 0.02

Australian Triage Scale

1 (%)

0

0

P = 0.484§

2

3

17

3

37

33

4

58

42

5

3

8

Length of ED admission

Mean minutes (SD)

201 (100)

256 (85)

P = 0.076

ED satisfaction rating

Mean (SD) out of 10

7.9 (1.8)

9.0 (1.1)

P = 0.018

Road distance from home to ED

Mean (SD) in km

4.6 (3.9)

5.1 (5.6)

P = 0.785

Road distance from home to GP

Mean (SD) in km

3.4 (3.0)

5.0 (4.2)

P = 0.276

Uses mobility aid

Yes (%)

70

30

P = 0.508

No (%)

81

19

Drives a car

Yes (%)

90

10

P = 0.051

No (%)

66

34

Owns a car

Yes (%)

85

15

P = 0.183

No (%)

65

35

Access to a driver

Yes (%)

97

3

P = 0.426

No (%)

92

8

LSNS-6 scoreǁ

Median (interquatile range)

17 (8)

13 (4)

P = 0.108§

Socially isolatedǁ

Yes (%)

80

20

P = 1.00

No (%)

75

25

Question 3 on Lubben Social Network Scale (Scale 0–5)#

Median response

4

2.5

P = 0.003§

*The test is between the participants who did and did not attend GP follow-up; Pearson chi-square (exact significance) test, two-sided. Independent samples t-test, equal variance not assumed, two-tailed; §Independent samples Mann–Whitney U-test, 2-sided. ǁLubben Social Network Scale – score <12 is defined as ‘socially isolated’; #’How many relatives do you feel close to such that you can call on them for help?’; scoring: 0, none; 1, one; 2, two; 3, three or four; 4, five to eight; 5, nine or more; ED, emergency department; GP general practitioner; SD, standard deviation

Implications for general practice

After an ED admission, it is possible that most older people follow up with their GP within days. Discharge summaries optimally need to be available at the time of discharge.

Some older people follow up with a GP who is not the addressee of the discharge summary. To assist in adequate clinical handover, discharge summaries may need to be communicated in a variety of methods including automating upload from ED to the national online My Health Record.

The absence of close family relationships and the lack of car transport may be barriers to general practice follow up after an ED admission.

Authors

Belinda Watson BSc(Med) (Hons), MD (candidate), School of Public Health and Community Medicine, UNSW Sydney, NSW

Chun Wah Michael Tam BSc(Med), MBBS, MMH (GP), FRACGP, Staff Specialist, General Practice Unit, South Western Sydney Local Health District & Ingham Institute of Applied Medical Research, Sydney, NSW; and Conjoint Senior Lecturer, UNSW Sydney, NSW. m.tam@unsw.edu.au

Belinda Pellizzon DASc (Nursing), GradDipCritCare(Emergency Nursing), DipPM, Nursing Unit Manager, Emergency Department, Fairfield Hospital, South Western Sydney Local Health District, Prairiewood, NSW

Lucille Ban MBBS,  Deputy Director, Emergency Department, Fairfield Hospital, South Western Sydney Local Health District, Prairiewood, NSW

Harry Doan MBBS, Director of Medical Services, Fairfield Hospital, South Western Sydney Local Health District, Prairiewood, NSW

Competing interests: None.

Provenance and peer review: Not commissioned, externally peer reviewed.

Acknowledgements

The researchers would like to acknowledge the assistance of the medical, nursing and administrative staff of the Fairfield ED and General Practice Unit in making this research project possible. They would also like to acknowledge the patients and family members who willingly gave their time and participated in the study. We thank Dr Andrew Knight for his comments on the drafts. Lastly, they would like to thank GP Synergy Ltd for providing a medical student scholarship and the opportunity to conduct this research.

References

  1. Arendts G, Lowthian J. Demography is destiny: An agenda for geriatric emergency medicine in Australasia. Emerg Med Australas 2013;25(3):271–78.
  2. Australian Institute of Health and Welfare. Australian hospital statistics 2012–13. Canberra: AIHW, 2014.
  3. Lowthian JA. Increasing demand for emergency patient services: Underlying drivers, implications and potential solutions. Melbourne: Monash University, 2011.
  4. George G, Jell C, Todd BS. Effect of population ageing on emergency department speed and efficiency: A historical perspective from a district general hospital in the UK. Emerg Med J 2006;23(5):379–83.
  5. Leonard C, Bein KJ, Latt M, Muscatello D, Veillard AS, Dinh MM. Demand for emergency department services in the elderly: An 11 year analysis of the Greater Sydney Area. Emerg Med Australas 2014;26(4):356–60.
  6. Arora VM, Farnan JM. Care transitions for hospitalized patients. Med Clin North Am 2008;92(2):315–24, viii.
  7. Mudge AM, Shakhovskoy R, Karrasch A. Quality of transitions in older medical patients with frequent readmissions: Opportunities for improvement. Eur J Intern Med 2013;24(8):779−83.
  8. Bauer M, Fitzgerald L, Haesler E, Manfrin M. Hospital discharge planning for frail older people and their family. Are we delivering best practice? A review of the evidence. J Clin Nurs 2009;18(18):2539–46.
  9. Lowthian J, Curtis A, Stoelwinder J, McNeil J, Cameron P. Emergency demand and repeat attendances by older patients. Intern Med J 2013;43(5):554–60.
  10. Council VQ. Clinical handover – Results arising from a clinical handover survey circulated to all Victorian public health service. Melbourne: Council VQ, 2006.
  11. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA 2007;297(8):831–41.
  12. Lane N, Bragg MJ. From emergency department to general practitioner: Evaluating emergency department communication and service to general practitioners. Emerg Med Australas 2007;19(4):346–52.
  13. Lubben J. Assessing social networks among elderly populations. J Fam and Comm Health 1988;11:42–52.
  14. Mazza D, Pearce C, Lowthian J, et al. REDIRECT: Reducing older patients’ avoidable presentations for emergency care treatment. Melbourne: Monash University, 2015.
  15. Chen Y, Brennan N, Magrabi F. Is email an effective method for hospital discharge communication? A randomized controlled trial to examine delivery of computer-generated discharge summaries by email, fax, post and patient hand delivery. Int J Med Inform 2010;79(3):167–72.
  16. Scott IA. Preventing the rebound: Improving care transition in hospital discharge processes. Aust Health Rev 2010;34(4):445–51.
  17. MacLeod KE, Ragland DR, Prohaska TR, Smith ML, Irmiter C, Satariano WA. Missed or delayed medical care appointments by older users of nonemergency medical transportation. Gerontologist 2015;55(6):1026–37.
  18. Korten AE, Jacomb PA, Jiao Z, et al. Predictors of GP service use: A community survey of an elderly Australian sample. Aust N Z J Public Health 1998;22(5):609–15.

 

Figure 1. Cumulative proportion of study participants who attended general practice follow up after emergency department discharge (days 0–7)

 

Correspondence afp@racgp.org.au

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