Risk taking in general practice: GP out-of-hours referrals to hospital.

BACKGROUND: Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers. AIM: To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital. DESIGN OF STUDY: Cross-sectional comparison of admission rates; postal survey. SETTING: Three OOH providers in south-west England. METHOD: Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk. RESULTS: There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low 'tolerance of risk' scores were more likely to be high referrers to hospital (P<0.001). CONCLUSION: GPs' threshold of risk is important for explaining variations in referral to hospital.

A qualitative study exploring variations in GPs' out-of-hours referrals to hospital.

BACKGROUND: There is evidence of significant variations in hospital referral rates for GPs working in out-of-hours care. AIMS: To explain why there are marked variations in hospital referral rates for GPs working in out-of-hours care. DESIGN OF STUDY: In depth, face-to-face interviews with a purposive sample of GPs with different out-of-hours referral rates. SETTING: Bristol, UK. METHOD: GPs were selected according to their rate of out-of-hours hospital referral. They were classified as high, medium, or low referrers. Five interviews were carried out with GPs from each of the three categories. RESULTS: High referring GPs are typically cautious and believe it is better to admit if in doubt. They express anxiety about the consequences of a decision not to admit, both for the patient and for themselves. They hold negative attitudes towards alternatives to hospital admission. Low referrers were more confident about their decisions and less often worried afterwards. Low referrers were positive about alternatives to hospital admission and described themselves as able to resist pressures from family or carers to have someone admitted. Low referrers also see hospitals as places to be avoided and viewed their goal as preventing an admission. CONCLUSION: Educational programmes need to be developed to improve GPs' judgements of their competences and to build appropriate levels of confidence.

An observational study of variation in GPs' out-of-hours emergency referrals.

Out-of-hours organisations are responsible for the care of patients 70% of the time, and their GPs act as gatekeepers to secondary care services. This observational study identifies the variations in GPs' out-of-hours referral rates to secondary care and factors that could explain these variations. One hundred and forty-nine GPs who worked in one UK general practice out-of-hours cooperative which served 19 practices with 167 000 registered patients. Data on patients who accessed the out-of-hours service over 3 years (2001-2004) were examined. Factors thought to be predictors of variation in referral rates were investigated using logistic regression analysis. There was a fivefold difference in referral rates between the lowest and highest referring quartiles of GPs (OR [odds ratio] = 4.56, CI [confidence interval] = 3.86 to 5.38). The sex (female) of the clinician, the time of the consultation (11 pm to 7 am), and the place of the consultation (home visit) accounted for some, but not all, of the increased referral rates. A doctor working out-of-hours disproportionately influences the fate of the patient, the number of hospital admissions, and extra costs to the health service. There is a need for follow-up studies to investigate the factors associated with referral behaviour, and how the variation relates to patient factors and the resources available. These findings could be used when planning the staffing of out-of-hours services to optimise appropriate care and minimise patients' exposure to unnecessary intrusive and expensive hospital care.