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Primary and community forms of emergency care cansubstitute for hospital accident and emergencydepartmentsRoberts E, Mays N. Can primary care and community-based models of emergency care substitute for the hospital accident and emergency (A&E)department? Health Policy 1998;44:191d214.

OBJECTIVE To assess the extent to which primary-secondarysubstitution is possible for emergency care

METHOD Systematic review of studies with a comparativeelement.

LITERATURE REVIEW Six electronic databases (includingMEDLINE), hand-searching, contact with experts; and referencechecking were used to identify potentially relevant studies.

INCLUSION CRITERIA

(a) Randomized controlled trials or quasi-experimental studiesor before-and-after studies or observational studies witha comparative analysis,

(b) Study population of people with conditions suitable fortreatment in primary and community settings (i.e. relatively minorillnesses)

(c) The nature of emergency care in the studies was first contactcare (no referral required) with capacity to treat urgent medicalproblems immediately.

(d) Study outcomes were objective measures of substitution (e.g.changes in A&E utilization rates).

DATA EXTRACTION AND SYNTHESIS Characteristics,quality and results of included studies were tabulated. Meta-analysiswas not conducted.

Evidence-based Healthcare (1999) 3, 106

RESULTS Thirty-four studies met the review inclusion criteria.Seventeen looked at the effect of primary-care-based interventions(improving access, improving provision of appointments,primary-care nurse practitioners and improving out of hoursservices). Three examined integration of primary and secondarycare in the A&E department (i.e. GPs based in the A&Edepartment). Fourteen evaluated specific emergency careinterventions (minor injuries clinics, telephone triage, redirectinginappropriate A&E attenders, and introducing user charges). Mostof the included studies had limitations. The results of includedstudies suggested that broadening access to primary care andintroducing user charges or other barriers to the hospital accidentand emergency (A&E) department can reduce demand forexpensive secondary care, although the relative cost-effectiveness ofsuch interventions remains unclear.

AUTHOR’S CONCLUSIONS Despite the limitations of theliterature reviewed, there is evidence that primary and communityforms of emergency care can substitute for the conventionalhospital A&E department.

CommentaryThe main conclusion to be drawn from this review is thatpronouncements about the delivery of emergency care are based onanecdote rather than on sound evidence. The authors found only fourrelevant randomized controlled trials. With such a paucity of evidence,this review raises many more questions than it is able to answer.

The absence of agreement about what constitutes an ‘emergency’ (andwhat, therefore, constitutes an ‘inappropriate’ attendance at an accidentand emergency department) hinders discussion and planning. There is littleconsensus among professionals. If the views of actual or potential patientswere included, the extent of disagreement may increase.

Each year in the United Kingdom there are millions of episodes ofcare for emergency problems. It is crucial to know the presentdistribution of this workload between primary and secondary care beforeplanning to change this distribution. Along with numbers treated, detailsof the nature of problems and outcomes are needed.

The data about employing primary care professionals in hospitalaccident and emergency departments are limited. There may be limits tothe external validity of these studies. The authors conclude that thiswould be cost-effective, but this measure has not been compared withother alternatives. One that merits attention is providing training foraccident and emergency staff, specifically about the management of‘minor’ conditions.

At present there is insufficient information to provide a basis forplanning changes. Before further initiatives are launched without priorresearch, this ignorance should be remedied. This area should receive,sooner rather than later, appropriate attention when research anddevelopment priorities are developed.

Dr Richard HardernThe General Infirmary

Leeds, UK

^ 1999 Harcourt Publishers Ltd