Rural emergency departments supplement general practice care

To the Editor: To provide a rural comparison to Nagree and colleagues' metropolitan study,1 we estimated the number of general practice-type patients attending emergency departments (EDs) in north-west Tasmania.

Ethics approval was granted by the Tasmanian Health and Medical Human Research Ethics Committee.

We used two methods of identifying general practice-type visits to analyse 152 481 ED presentations to the North West Regional Hospital (Burnie) and the Mersey Community Hospital (Latrobe) from January 2011 to December 2013.

The Australasian College for Emergency Medicine (ACEM) method categorises as possibly suitable for a general practice consultation patients who are self-referred, do not arrive by ambulance and have a medical consultation time under 1 hour. Patients who did not wait to be seen by a doctor or had an invalid treatment time are excluded. Over the 3 years, we identified 51 770 general practice-type presentations using this method (34.9%). There were 60 684 presentations included in the ACEM method on weekdays, with 19 541 (32.2%) identified as general practice-type patients (Box). However, ACEM general practice-type patients occupied only 7%–8% of total ED treatment time.

The Australian Institute of Health and Welfare (AIHW) method categorises as general practice-type those patients who: are allocated to an Australasian Triage Scale category of 4 or 5 (specifying 60- and 120-minute maximum waiting times, respectively); do not arrive by ambulance, police, community health or correctional vehicle; are not admitted to hospital; and do not die. Using this method, 82 645 general practice-type patients (54.2% of all ED patients) were identified. Such presentations occupied 25% of total ED treatment time each year.

Our results indicate that the proportion of presentations to EDs in north-west Tasmania that are general practice-type visits is two to three times that in Perth.1

In rural areas, the lack of availability of general practice care at no cost to the patient is a main reason for patients presenting to EDs.2 There are 118 general practitioners in north-west Tasmania, or 104.4 per 100 000 persons; half that of major cities (227.8 per 100 000).3,4 With fewer GPs, residents are likely to appropriately self-refer to EDs to access care. Increasing the supply of GPs in rural areas remains the cornerstone of reducing general practice-type admissions.

As north-west Tasmania is an area of high socioeconomic disadvantage, it is reasonable to expect that cost weighs heavily in many residents' decisions concerning health care. Implementing a policy such as the $5 general practice copayment may increase ED presentations among the working poor in order to avoid paying.

Different models of care for appropriately managing GP-type presentations to EDs have been suggested. Employing GPs in EDs has been shown to reduce costs,5 but in rural areas with a shortage of GPs this would take them away from their practices. Other models of providing care in less expensive settings than tertiary EDs require exploration. One such model may be a parallel low-acuity service staffed by nurses and overseen by an emergency medicine registrar or specialist.