Emergency department referral patterns of Australian general practitioner registrars: a cross-sectional analysis of prevalence, nature and associations
Nigel Catzikiris A B H , Amanda Tapley A B , Simon Morgan A , Mieke van Driel C , Neil Spike D E , Elizabeth G. Holliday B F , Jean Ball F , Kim Henderson A B , Lawrie McArthur G and Parker Magin A BA GP Synergy, NSW and ACT Research and Evaluation Unit, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia. Email: Amanda_tapley@gpsynergy.com.au; lochswilly@gmail.com; kim_pinkerton@gpsynergy.com.au; parker_magin@gpsynergy.com.au
B School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia.
C Discipline of General Practice, School of Medicine, University of Queensland, Level 8 Health Sciences Building, Royal Brisbane and Women’s Hospital, Brisbane, Qld 4029, Australia.
D Eastern Victoria GP Training, 15 Cato Street, Hawthorn, Vic. 3122, Australia. Email: neil.spike@evgptraining.com.au
E Department of General Practice, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia.
F Public Health Research Program, Hunter Medical Research Institute, Locked Bag 1000, New Lambton, NSW 2305, Australia. Email: Elizabeth.Holliday@hmri.com.au; Jean.Ball@hmri.com.au
G Discipline of General Practice, University of Adelaide, 183 Melbourne Street, North Adelaide, SA 5006, Australia. Email: lawrie.mcarthur@adelaide.edu.au
H Corresponding author. Email: nigel_catzikiris@gpsynergy.com.au
Australian Health Review 43(1) 21-28 https://doi.org/10.1071/AH17005
Submitted: 11 January 2017 Accepted: 28 September 2017 Published: 9 November 2017
Journal Compilation © AHHA 2019 Open Access CC BY-NC-ND
Abstract
Objective Limited international evidence suggests general practice registrars’ emergency department (ED) referral rates exceed those of established general practitioners (GPs). The aim of the present study was to fill an evidence gap by establishing the prevalence, nature and associations of Australian GP registrar ED referrals.
Methods A cross-sectional analysis was performed of the Registrar Clinical Encounters in Training (ReCEnT) cohort study of GP registrars’ consultation experiences, between 2010 and 2015. The outcome factor in logistic regression analysis was referral to an ED. Independent variables included patient-level, registrar-level, practice-level and consultation-level factors.
Results In all, 1161 GP registrars (response rate 95.5%) contributed data from 166 966 consultations, comprising 258 381 individual problems. Based on responses, 0.5% of problems resulted in ED referral, of which nearly 25% comprised chest pain, abdominal pain and fractures. Significant (P < 0.05) associations of ED referral included patient age <15 and >34 years, the patient being new to the registrar, one particular regional training provider (RTP), in-consultation information or assistance being sought and learning goals being generated. Outer regional-, remote- or very remote-based registrars made significantly fewer ED referrals than more urban registrars. Of the problems referred to the ED, 45.5% involved the seeking of in-consultation information or assistance, predominantly from supervisors.
Conclusions Registrars’ ED referral rates are nearly twice those of established GPs. The findings of the present study suggest acute illnesses or injuries present registrars with clinical challenges and real learning opportunities, and highlight the importance of continuity of care, even for acute presentations.
What is known about the topic? A GP’s decision concerning continued community- versus hospital-based management of acute presentations demands careful consideration of a suite of factors, including implications for patient care and resource expenditure. General practice vocational training is a critical period for the development of GP registrars’ long-term patterns of practice. Although limited international evidence suggests GP registrars and early career GPs refer patients to the ED at a higher rate than their more experienced peers, these studies involved small subject numbers and did not investigate associations of registrars making an ED referral. Relevant Australian studies focusing on GP registrars’ ED referral patterns are lacking.
What does this paper add? The present ongoing cohort study is the first to establish the patterns of ED referrals made by Australian GP registrars, encompassing five general practice RTPs across five states, with participating registrars practising in urban, rural, remote and very remote practices. Several significant associations were found with GP registrars making ED referrals, including patient age, continuity of care, the registrar’s RTP, assistance sought by the registrar and rurality of the registrar’s practice.
What are the implications for practitioners? The higher likelihood of GP registrars seeing acute presentations than their more established practice colleagues, coupled with a demonstrated association of registrars seeking in-consultation assistance for such presentations, highlights the importance of GP supervisor accessibility in facilitating ED referral appropriateness and in the development of registrars’ safe clinical practice.
Additional keywords: emergency medicine, family practice, general practice, physician practice patterns, referral and consultation.
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