Jon Nicoll: Induced demand and use of emergency care
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Jon Nicoll: Induced demand and use of emergency care

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This presentation was given by Jon Nicoll, Professor of Health Services Research in the School of Health and Related Research (ScHARR) at the University of Sheffield. He discusses induced demand and ...

This presentation was given by Jon Nicoll, Professor of Health Services Research in the School of Health and Related Research (ScHARR) at the University of Sheffield. He discusses induced demand and utilisation of the emergency and urgent care system and how services such as walk-in centres and phone lines can affect demand and utilisation.

Professor Nicoll spoke at the event: "Supply induced demand as it relates to general practice" (http://www.nuffieldtrust.org.uk/talks/supply-induced-demand-it-relates-general-practice) in March 2014.

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  • Not primary care as such. F-to-f services <br />
  • But note that GP day time activity is missing <br />
  • Type 2 induced demand doesn’t include other because although these patients went wic+other they would have gone other+wic. In contrst those who went wic+ed/gp would have gone just to ed/gp. <br />
  • Type 2 induced demand doesn’t include other because although these patients went wic+other they would have gone other+wic. In contrst those who went wic+ed/gp would have gone just to ed/gp. <br />
  • Type 2 induced demand doesn’t include other because although these patients went wic+other they would have gone other+wic. In contrst those who went wic+ed/gp would have gone just to ed/gp. <br />
  • This is not all induced demand. It may be diverted from day time GP. <br />

Jon Nicoll: Induced demand and use of emergency care Presentation Transcript

  • 1. Induced demand for and utilisation of the emergency and urgent care system Jon Nicholl ScHARR, Sheffield
  • 2. Induced demand and utilisation for face-to-face services 1. First contacts for new problems (demand) (affected by accessibility) 2. Further contacts for the same problem (utilisation) (affected by appropriateness of first contact)
  • 3. Induced demand and utilisation by call lines • Call lines could alter demand and utilisation of existing services, for example by o Increasing demand by advising some people who would have looked after themselves to make f-to-f contact, or o Reducing utilisation by sending people to the right place first time, and reducing the need for further contacts for the same problem
  • 4. Studies of NHS Direct and NHS111 show that call lines do not appear to alter utilisation http://www.sheffield.ac.uk/scharr/sections/hsr/mcru/reports. Turner et al. BMJ Open 2013. doi:10.1136/bmjopen-2013-003451 % change in system activity following start of NHS111 in 4 pilot sites relative to control sites
  • 5. Commuter WICs
  • 6. Induced demand by commuter WICs Self-reported pre-consultation intentions in patients attending 6 privately managed, Dr staffed, commuter walk-in centres Pre-consultation intentions (What would you have done if the WIC had not been available?) N (%) ED 139 (11.7) GP 631 (53.2) Other 228 (19.2) Self/nothing 189 (15.9) Total 1187(100.0%)
  • 7. Induced potential utilisation by commuter WICs Self-reported post-consultation plans in patients attending 6 privately managed, Dr staffed, commuter walk-in centres Pre-consultation intentions (What would you have done if the WIC had not been available?) N (%) Post-consultation plans N (%) ED 139 (11.7) 74 (5.0) GP 631 (53.2) 368 (25.0) Other 228 (19.2) 295 (20.0) Self/nothing 189 (15.9) 737 (50.0) Total 1187(100.0%) 1474 (100.0%) O’Cathain et al. BJGP 2009. doi: 10.3399/bjgpo9X473150. Coster et al. BJGP 2009. doi: 10.3399/bjgpo9X473169
  • 8. GP-led Urgent care centres
  • 9. Induced demand by GP-led urgent care centres Self-reported pre-consultation intentions in patients attending two privately managed, Dr staffed, urgent care centres Pre-consultation intentions (What would you have done if the GP-WIC had not been available?) N (%) ED 202 (23.2) GP 340 (39.0) Other 226 (25.9) Self/nothing 103 (11.8) Total 871 (100.0%) Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410
  • 10. Induced potential utilisation by GP-led urgent care centres Self-reported post-consultation plans in patients attending two privately managed, Dr staffed, urgent care centres Pre-consultation intentions (What would you have done if the GP-WIC had not been available?) N (%) Post-consultation plans N (%) ED 202 (23.2) 38 (4.4) GP 340 (39.0) 146 (16.7) Other 226 (25.9) 30 (3.4) Self/nothing 103 (11.8) 659 (75.5) Total 871 (100.0%) 873 (100.0%) Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410
  • 11. Induced utilisation by GP-led urgent care centres Self-reported 4 wk post-consultation use of other services by patients attending two privately managed, Dr staffed, urgent care centres Pre-consultation intentions (What would you have done if the GP-WIC had not been available?) N (%) Post-consultation plans N (%) Actual use of services post-consultation N (%) ED 202 (23.2) 38 (4.4) 14 (5.6) GP 340 (39.0) 146 (16.7) 73 (29.3) Other 226 (25.9) 30 (3.4) 21 (8.8) Self/nothing 103 (11.8) 659 (75.5) 141 (56.2) Total 871 (100.0%) 873 (100.0%) 249 (100.0) Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410
  • 12. Estimating the volume of induced utilisation • Call lines don’t appear to change demand or utilisation • Demand: 12-16% of patients attending walk-in urgent care centres said that they would not have made any contact if the service hadn’t been available • Utilisation: 30-35% of patients who use walk-in urgent care centres go on to contact their GP or an ED
  • 13. Estimating the volume of induced urgent care first attenders at type 3 EDs In 2012/13 there were 6.6m type 3 ED contacts There were an unknown N of type 3 ED minor injury unit attendances in 1994/5
  • 14. Estimating the volume of induced utilisation • MIUs began to be introduced in the 1990s • GP and nurse-led walk-in centres began to be introduced in 2000. • Assuming about 1/3rd of type 3 ED attendances are to MIUs, the WICs and UCCs may induce about • 0.5m new contacts each year • 1.5m follow-on contacts
  • 15. Big uncertainties • Small studies not designed to answer this question • Response rates • Reliability of reported intentions • The volume of MIU attendances which may induce relatively little additional utilisation • The longer term effects of call lines when they have bedded-in.
  • 16. Big uncertainties • Small studies not designed to answer this question • Response rates • Reliability of reported intentions • The volume of MIU attendances which may induce relatively little additional utilisation • The longer term effects of call lines when they have bedded-in. Thank you
  • 17. Copyright ©2000 BMJ Publishing Group Ltd. Munro, J. et al. BMJ 2000;321:150-153 Impact of NHS Direct on emergency and urgent care services
  • 18. Intentions and outcomes in 249 patients attending two GP-WICs What would you have done if the GP-WIC had not been available? Intention to use other services after consultation Outcome ED 202 (23.2) 38 14 (5.6) GP 340 (39.0) 146 73 (29.3) Self/nothing 103 (11.8) 659 - GP-WIC - 8 141 (56.2) Other 226 (25.9) 22 21 (8.8) Total 871 (100.0%) 873 (100.0%) 249 (100.0) We know that the 23.2% who said they would have gone to ED exaggerates the true proportion. So
  • 19. Intentions and outcomes in patients attending two GP-WICs What would you have done if the GP-WIC had not been available? Intention to use other services after consultation Outcome ED 202 (23.2) 38 14 (5.6) GP 340 (39.0) 146 73 (29.3) Other 226 (25.9) 30 21 (8.8) Self/nothing 103 (11.8) 659 141 (56.2) Total 871 (100.0%) 873 (100.0%) 249 (100.0) We know that the 23.2% who said they would have gone to ED exaggerates the true proportion who would have gone to ED. So, other intentions are likely to be unreliable.