PRIMARY-CARE IN THE ACCIDENT AND EMERGENCY DEPARTMENT .2. COMPARISON OF GENERAL-PRACTITIONERS AND HOSPITAL DOCTORS

Objective-To compare the process and outcome of ''primary care'' consu ltations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department. Design-Prospect ive, controlled intervention study. Setting-A busy, inner city acciden t and emergency department in south London. Subjects-Patients treated during a stratified random sample of 419 three hour sessions between J une 1989 and May 1990 assessed at nurse triage as presenting with prob lems that could be treated in a primary care setting. 1702 of these pa tients were treated by sessionally employed local general practitioner s, 2382 by senior house officers, and 557 by registrars. Main outcome measures-Process variables: laboratory and radiographic investigations , prescriptions, and referrals; outcome variables: results of investig ations. Results-Primary care consultations made by accident and emerge ncy medical staff resulted in greater utilisation of investigative, ou tpatient, and specialist services than those made by general practitio ners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house offi cer v general practitioner consultations and 2.37 (1.84 to 3.06) for r egistrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v g eneral practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners. Conclusion-Employing general practitioners in accident and emergency departments to manage patients with primary care needs s eems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utili sation, but the impact on patient outcome and satisfaction needs to be considered further.