Issue 48 / 10 December 2012

A CALL by leading emergency physicians for an urgent review of the Australian Institute of Health and Welfare’s “flawed” method of calculating the number of general practice presentations to emergency departments is likely to be answered by the middle of next year.

In a letter published in the MJA this week, the emergency doctors said recent AIHW statistics showed 38% of ED attendances from July 2011 to June 2012 were potential GP presentations, whereas the true figure was likely to be one-third of that number. (1)

The authors wrote that the AIHW method of reporting was flawed because of erroneous use of the Australasian Triage Scale.

Although the AIHW and Council of Australian Governments (COAG) had acknowledged the indicator was flawed and had agreed to review it, to date this had not been done and it was now “a matter of national urgency”, they wrote.

Ms Jenny Hargreaves, a senior executive of the AIHW Hospitals and Performance Group, told MJA InSight the intention was that “the indicator is revised by mid next year and if possible we’ll use it in the September [2013] report”.

“It is appreciated that this is not a perfect indicator, that is why we are reviewing it”, Ms Hargreaves said.

Lead author of the MJA letter, Professor Yusuf Nagree, of the School of Primary, Aboriginal and Rural Health Care at the University of WA, said it was more than 2 years since the Australasian College for Emergency Medicine first raised the alarm bell about the AIHW’s “corruption of the triage scale”.

Under the AIHW indicator, people who come to an emergency department who are triaged as category 4 or 5 are considered a GP-related referral. This includes any patient referred to an ED by a GP.

The letter authors wrote: “Partly based on the inaccurate AIHW statistics suggesting EDs have more general practice patients than they really do, policy initiatives have been introduced in recent years to redirect these patients away from EDs (eg, the nurse walk-in centres in Canberra, national telephone triage lines and super clinics).

“These programs have cost many millions of dollars but failed to have any meaningful impact on overcrowding in EDs.”

Instead, the focus should be the true solution — increasing inpatient bed capacity, the authors wrote.

Professor Daniel Fatovich, professor of emergency medicine at the University of WA and a coauthor of the letter, told MJA InSight other reputable methods had found that potential GP presentations accounted for about 10% of ED attendances but only about 3% when calculated as a proportion of time spent with patients.

“It is such a tiny part yet it seems to garner incredible attention that is completely out of proportion”, he said.

“That there are too many inappropriate GP cases is a complete myth and policy makers seem to have fallen for it — they have started to introduce policies based on it.” The indicator was not used by any other country, he said.

He said based on his experience as an emergency physician at Royal Perth Hospital, potential GP presentations accounted for only about 5% of ED attendances.

Another coauthor, Professor Peter Cameron, professor of emergency medicine at Monash University, told MJA InSight the triage scale used by EDs was developed as a measure of urgency not as a measure of severity of illness or likelihood of admission.

Professor Cameron said the main reason for AIHW adopting the method was “probably laziness” as it was taken from NSW state government reports.

“It suited the political argument that access block in EDs could be fixed by sending [patients] to their GPs — this suits state governments who fund hospitals”, he said.

Ms Hargreaves would not comment on the authors’ assertion that the erroneous statistics had led to poor policy outcomes and a waste of resources, saying that “the AIHW is not a policy-making body”.

However, she said the institute would consider the letter when reviewing the indicator.

– Amanda Saunders

1. MJA 2012; 197: 619

Posted 10 December 2012

18 thoughts on ““Flawed” method dictates ED numbers

  1. Anonymous says:

    So if the Government now wants to measure GP performance we can expect the same political priorities to come before analytical rigour? Keep the politicians out of the consulting room thanks.

  2. Chris Lawson says:

    The AIHW report makes it clear that triage classes don’t reflect need for admission and Table 2.9 shows the patient outcomes by triage class — in 2011/12, 544,000 patients triaged as not urgent or only semi-urgent were admitted, and 64 died in the emergency department. It’s poor health policy to use this data to decide how many ED presentations could be handled by GPs, but that’s not all the AIHW’s fault.

  3. Sally says:

    I can accept that the ATS is a tool designed for triaging urgency of care and not ‘GP’ vs ‘non-GP’ presentations. But, could someone explain why Cat 4 and 5 patients, being relatively ‘non-urgent’ cases, belong in an ‘Emergency’ department? And if they don’t belong there, then where do they belong?

  4. Rose says:

    Get ready for it to get worse-Medicare is no longer wanting to pay GPs to do their own after-hours – I do not intend to donate to their designated recipient of my work-have a sign saying after hours consultations require an upfront large cash payment , so if you do not have the necessary legal tender, I hope you have NBN to skype your Medicare Local, ED, Julia Gillard but do not bother me for I will be sleeping in my bed

  5. Liz says:

    Sally, if I break my scaphoid in a fall (which I have done once), its quite reasonable to attend an emergency department for treatment. However there is no argument that I need to be seen within 4 hours – no major swelling is expected, pain can be controlled until a cast is applied. Easily category 4 or 5 on the triage scale, but still quite reasonable to attend an ED. Of course, your rural local doc could probably do this in their rooms too, and your friend could drive you round to X-ray and back to the rooms for the cast to be applied.

  6. Rose says:

    While we rural docs can manage a plaster, we are not Superman nor Superwoman with xray vision, so after hours we rely on our only access to imaging (and Pathology, Pharmacy,) in most areas-the ED.
    Medicare expects GPs to work 24 hours per day, 7 days per week, yet does not require the same of imaging, pathology providers, nor pharmacy , nor allied health, nor dentists, so this inequity is one of the reasons that category 4 and 5 patients present to the ED after hours .

  7. Sue says:

    The ED triage categories are a measure of URGENCY only, and are only relevant for sorting priority between patients competing for care. The urgency rating is time-based – a Cat 4 patient should have to wait no longer than an hour. This is whole difference concept to waiting times in the commmunity, where patients may wait days, weeks for months for an appointment. ED triage categories do not reflect either complexity or severity, or any sort of “appropriateness”. An old lady with mild confusion, recurrent falls and possible UTI, which has been developing over a period of days, is safe to wait an hour for treatment – making her triage category 4. Does that mean she should be re-directed to her GP. And if she was extensively investigated, seen by the aged care team and the physio, and eventually discharged – does that make her an “inappropriate attendance” at an ED? We need to get over blaming the patients for seeking care, get over the cost-shifting forces and just provide good care where it is most effective and efficient for patients. If it is the ED, support EDs to do it well – don’t blame us for providing a service that patients need.

  8. Rose says:

    “Get over the cost-shifting”-cost-shifting is the core issue-hospitals are funded with State funding (apportioned from Federal money to each state) and the underhand attempt of cost-shifting from the State hospitals to we GPs, who are funded by Federal Medicare money, while State hospitals keep the funding , is double-dipping by State hospitals who want the funding, but do not want to spend it on ED (or any) patients.

  9. Philip Dawson says:

    What is a referral to emergency for some GPs is standard GP care fo others-we wouldnt refer any scaphoid fractures to emergency, we have our own xray machine and plaster/synthetics. Many fracture patients actually present the next day (or two if they have been drinking a lot) so undisplaced fractures are clearly not a middle of the night category 1 or two emergency. Lacerations are sewn up by many GPs, but others dont want to do any. What I would be interested in is how many emergency department patients are sent home shortly after being seen by a doctor-clearly GP material? How many patients never see a GP but just go to emergency when ill? Cost is a factor-we charge a reasonable gap for weekends and after hours, some patients will want to spend their time waiting 6 hours in emergency rather than their dollars seeing a GP.

  10. Sue Ieraci says:

    Philip Dawson – that variability in what GPs provide is one of the reasons the term “GP-type patient” makes no sense. It all depends on what that individual GP’s capability, capacity, availability and risk-tolerance is for each individual encounter. Some patients who are sent home shortly after being seen are referred by a GP, seeking a second opinion. That is a legitimate role for EDs, and costs next to nothing. It is know that the group of people most likely to seek episodic care from an ED is young men. Much of their care is injury-related and non-complex – again, little burden on the ED. ED’s largest and most complex workload is consists of the elderly with multiple co-morbidities – also the group most subject to access block. What alternatives are available at short-notice, 24 hours, seven days, for these people? Why not just resource EDs to do this work, which they do well?

  11. Saint from Elsewhere says:

    Thank you Sue! ATS 4 which “should wait no longer than an hour” and in some hospitals is the largest category of admitted patients and death-within-a-week, are often referred by GPs, and admitted from ED to theatre, are clearly not “GP patients.”
    Dr Lawson, emergency physicians have been trying to explain the difference between urgent and important for decades now, the AIHW is ignoring information not only freely available but positively pushed at it! And btw – dying in the ED may be the only option when inpatient beds are not available, palliative care services tell their patients to come to ED after hours, and nursing homes are sometimes unwilling to allow clearly terminal patients to die in their beds. It is not an indication of inappropriate triage. Such presentations vary throughout the country depending on other resources including availability of GPs willing and resourced to care for dying patients in the community, so deaths after presention are not a useful measure of triage or ED performance.

  12. Growler says:

    The article is right. I’ve seen LOTS of fractures (in particular, # NoF) triaged as 4. And the government reckons this is a GP item?

  13. peter arvier says:

    We need a re-think on calling our work places “Emergency” Departments and staffing them with “Emergency” Physicians when true emergencies are a such a tiny proportion of the workload. It’s not up to us to dictate what comes through the front door. Similarly why do we concentrate training for medical staff largely at the high acuity end of the spectrum?

    It’s about time to approach it from the patient’s and community’s perspective and provide the services that they need – not just what we would like to provide. This might be quite different for a tertiary metropolitan hospital compared with a regional general hospital. Pouring resources into GP Superclinics was never going to be the answer.

  14. Sue says:

    With respect, Peter, it appears that EDs are already providing what the community needs, as our workloads are growing faster than the population, despite decades of trying to “deflect” the workload. I don’t see any sense in the term “true emergency” – what we provide is rapid-access unscheduled care, mostly time-dependent, and often complex. In comparison to the rest of the community, being seen on the same day, turning up unannounced, is rapid access. Many of us have now moved to the concept of complexity, alongside urgency – they are two separate dimensions. Emergency medicine training is not just about resuscitation – the curriculum covers complex problem-solving throughout the spectrum of illness and injury. The community seems to value the service. If there were not a federal-state funding split, perhaps we could stop trying to define the service and allow the community to access it when they need to.

  15. Rose says:

    Resource EDs to do the work, and fund it with Medicare Local money -if Medicare Locals want the GP PIP payment for after-hours, let this money be paid to fund EDs in each region.

  16. Sue Ieraci says:

    That would require an end to the federal/state funding split between hospital services and community practice, with funding being directed on the basis of need and cost-effectiveness. A novel idea indeed!

  17. Rose says:

    Has anyone considered that the inadequate funding of EDs and ED congestion due to shortage of inpatient beds has suited some private-billing GPs some GP VMOs and some private Specialists, financially, in the short-term, so that a deal appears to have been done with Area Health Services, whose aim has been to downgrade Rural Hospitals, to the extent that we now see what was a Hospital now not a hospital, but a Minus Medical Practitioner Service, or a nursing home, while Medicare Locals have increased funding to pay private Specialists and transport patients to them?

  18. Sue Ieraci says:

    Rose – that might be a possibility, but ED overcrowding is much worse in the big urban EDs – largely due to a combination of risk aversion and bed access block.

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