Interventions in primary and community care to reduce urgent paediatric hospital admissions: systematic review.

BACKGROUND: There has been a rise in urgent paediatric hospital admissions and interventions to address this are required. OBJECTIVE: To systemically review the literature describing community (or non-hospital)-based interventions designed to reduce emergency department (ED) visits or urgent hospital admissions. DATA SOURCES: MEDLINE, Embase, OVIS SP, PsycINFO, Science Citation Index Expanded/ISI Web of Science (1981-present), the Cochrane Library database and the Database of Abstracts of Reviews of Effectiveness. STUDY ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) and before-and-after studies. PARTICIPANTS: Individuals aged <16 years. STUDY APPRAISAL AND SYNTHESIS METHODS: Papers were independently reviewed by two researchers. Data extraction and the Critical Appraisals Skills Programme checklist was completed (for risk of bias assessment). RESULTS: Seven studies were identified. Three studies were RCTs, three were a comparison between non-randomised groups and one was a before-and-after study. Interventions were reconfiguration of staff roles (two papers), telemedicine (three papers), pathways of urgent care (one paper) and point-of-care testing (one paper). Reconfiguration of staff roles resulted in reduction in ED visits in one study (with a commensurate increase in general practitioner visits) but increased hospital admissions from ED in a second. Telemedicine was associated with a reduction in children's admissions in one study and reduced ED admissions in two further studies. Interventions with pathways of care and point-of-care testing did not impact either ED visits or urgent admissions. CONCLUSIONS AND IMPLICATIONS: New out-of-hospital models of urgent care for children need to be introduced and evaluated without delay. PROSPERO REGISTRATION NUMBER: CRD42021274374.

Interventions to reduce acute paediatric hospital admissions: a systematic review.

BACKGROUND: Admission rates are rising despite no change to burden of illness, and interventions to reduce unscheduled admission to hospital safely may be justified. OBJECTIVE: To systematically examine admission prevention strategies and report long-term follow-up of admission prevention initiatives. DATA SOURCES: MEDLINE, Embase, OVID SP, PsychINFO, Science Citation Index Expanded/ISI Web of Science, The Cochrane Library from inception to time of writing. Reference lists were hand searched. STUDY ELIGIBILITY CRITERIA: Randomised controlled trials and before-and-after studies. PARTICIPANTS: Individuals aged <18 years. STUDY APPRAISAL AND SYNTHESIS METHODS: Studies were independently screened by two reviewers with final screening by a third. Data extraction and the Critical Appraisals Skills Programme checklist completion (for risk of bias assessment) were performed by one reviewer and checked by a second. RESULTS: Twenty-eight studies were included of whom 24 were before-and-after studies and 4 were studies comparing outcomes between non-randomised groups. Interventions included referral pathways, staff reconfiguration, new healthcare facilities and telemedicine. The strongest evidence for admission prevention was seen in asthma-specific referral pathways (n=6) showing 34% (95% CI 28 to 39) reduction, but with evidence of publication bias. Other pathways showed inconsistent results or were insufficient for wider interpretation. Staffing reconfiguration showed reduced admissions in two studies, and shorter length of stay in one. Short stay admission units reduced admissions in three studies. CONCLUSIONS AND IMPLICATIONS: There is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.

Variation in referrals from primary care to scheduled paediatric services in North and East Scotland -a cross-sectional study.

BACKGROUND: Factors contributing to decisions to refer children for scheduled appointments at medical paediatric outpatient clinics are not well understood. Our aim was to describe practice-level characteristics associated with referrals to general paediatric clinics. METHODS: In this cross-sectional study the setting was general practices in three health boards in Scotland, NHS Grampian, NHS Highland and NHS Tayside The outcome was average annual number of referrals per 1000 children between 2011 and 2017. Univariate and multivariate analyses related the outcome to practice characteristics. For each practice the following characteristics were determined: distance from hospital; area deprivation; number of children registered; presence of ≥ 1 general practitioner with a child health interest and practice ownership. RESULTS: There were 62 practices in NHS Grampian, 63 in NHS Highland, and 65 in NHS Tayside; representative annual number of referrals to paediatric clinics per capita were 22, 34, and 35/1000 respectively. In the multivariate model, the number of referrals was inversely related to number of children in the practice (0.8 % fall per 1000 children [95 % confidence interval, CI, 0.5, 1.1]) and was higher from practices in the more deprived areas by a mean 55 % [95 % CI 9, 121] compared to less deprived areas. The number of referrals from a practice rose by 0.91 % [95 % CI 0.86, 0.97] for each additional partner in the practice. CONCLUSION: Some practice-level characteristics were related to the standardised number of referrals, and associations differed between regions.