Department of Primary Care and Public Health, Imperial College London, London, UK.
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
BMJ Qual Saf. 2018 Aug;27(8):643-654. doi: 10.1136/bmjqs-2017-007174. Epub 2018 Jan 22.
The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England.
The study included 8124 general practices between 2011-2012 and 2013-2014. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours and overall experience (on 0-100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification.
Mean practice-level rates of A&E visits and emergency admissions increased from 2011-2012 to 2013-2014 (310.3-324.4 and 98.8-102.9 per 1000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011-2012 and 76.6 in 2013-2014. In the adjusted regression analysis, an SD increase in experience of making appointments (equal to 9 points) predicted decreases of 1.8% (95% CI -2.4% to -1.2%) in A&E visit rates and 1.4% (95% CI -1.9% to -0.9%) in admission rates. This equalled 301 174 fewer A&E visits and 74 610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses.
Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E visits and emergency admissions.
英国政府出台了多项旨在改善初级保健服务可及性的国家政策。我们研究了一般实践中患者体验与英国事故和急诊部（A&E）就诊率和急诊住院率之间的关系。
该研究纳入了 2011-2012 年至 2013-2014 年的 8124 家全科诊所。根据医院行政记录，将全科诊所人群的年 A&E 就诊率和急诊住院率作为结局指标。解释变量包括全科医师患者调查中的三项患者体验措施：预约体验、营业时间满意度和整体体验的平均值（在 0-100 分尺度上）。主要分析采用横截面时间序列的随机效应泊松回归。五项敏感性分析检查了模型规格的变化。
从 2011-2012 年到 2013-2014 年，平均实践水平的 A&E 就诊率和急诊住院率上升（每 1000 名患者分别为 310.3-324.4 和 98.8-102.9）。每项患者体验指标均下降；例如，2011-2012 年的营业时间满意度平均值为 79.4，2013-2014 年为 76.6。在调整后的回归分析中，预约体验的标准差增加（等于 9 分）预测 A&E 就诊率下降 1.8%（95%CI-2.4%至-1.2%）和住院率下降 1.4%（95%CI-1.9%至-0.9%）。这相当于全国每年减少 301174 次 A&E 就诊和 74610 次住院。在主要和敏感性分析中，营业时间满意度和整体体验与任何结局指标均无一致关联。
一般实践中患者体验与急诊医院服务利用之间的关联较小或不一致。在英格兰，对一般实践中患者体验的现实短期改善可能对 A&E 就诊率和急诊住院率只有适度影响。
