Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices

Abstract

Background: In the UK, while most primary care contacts are uncomplicated, safety incidents do occur and result in patient harm, for example, failure to recognise a patient's deterioration in health.

Aim: To determine the patient and healthcare factors associated with potentially missed acute deterioration in health.

Design and setting: Cohort of patients registered with English Clinical Practice Research Datalink general practices between 1 April 2014 and 31 December 2017 with linked hospital data.

Method: A potentially missed acute deterioration was defined as a patient having a self-referred admission to hospital having been seen in primary care by a GP in the 3 days beforehand. All diagnoses and subsets of commonly-reported missed conditions were analysed..

Results: A total of 116 097 patients contacted a GP 3 days before an emergency admission. Patients with sepsis (adjusted odds ratio [aOR] 1.09, 95% confidence interval [CI] = 1.01 to 1.18) or urinary tract infections (aOR 1.09, 95% CI = 1.04 to 1.14) were more likely to self-refer. The duration of GP appointments was associated with self-referral. On average, a 5-minute increase in appointment time resulted in a 10% decrease in the odds of self-referred admissions (aOR 0.90, 95% CI = 0.89 to 0.91). Patients having a telephone consultation (compared with face-to-face consultation) (aOR 1.14, 95% CI = 1.11 to 1.18) previous health service use, and presence of comorbidities were also associated with self-referred admission.

Conclusion: Differentiating acute deterioration from self-limiting conditions can be difficult for clinicians, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The findings of this study support the call for longer GP consultations and caution against reliance on telephone consultations in primary care; however, more research is needed to understand the underlying mechanisms.

Keywords: emergency hospital admissions; health deterioration; patient safety; primary care; sepsis; urinary tract infections.