title: Reducing inappropriate accident and emergency department attendances: a systematic review of primary care service interventions.
abstract: BACKGROUND
  Inappropriate attendances may account for up to 40% of presentations at accident and emergency (A&E) departments. There is considerable interest from health practitioners and policymakers in interventions to reduce this burden.
  
  
  OBJECTIVE
  To review the evidence on primary care service interventions to reduce inappropriate A&E attendances.
  
  
  METHODS
  Systematic review of UK and international primary care interventions.
  
  
  METHODS
  Studies published in English between 1 January 1986 and 23 August 2011 were identified from PubMed, the NHS Economic Evaluation Database, the Cochrane Collaboration, and Health Technology Assessment databases. The outcome measures were A&E attendances, patient satisfaction, clinical outcome, and intervention cost. Two authors reviewed titles and abstracts of retrieved results, with adjudication of disagreements conducted by the third. Studies were quality assessed using the Scottish Intercollegiate Guidelines Network checklist system where applicable.
  
  
  RESULTS
  In total, 9916 manuscripts were identified, of which 34 were reviewed. Telephone triage was the single best-evaluated intervention. This resulted in negligible impact on A&E attendance, but exhibited acceptable patient satisfaction and clinical safety; cost effectiveness was uncertain. The limited available evidence suggests that emergency nurse practitioners in community settings and community health centres may reduce A&E attendance. For all other interventions considered in this review (walk-in centres, minor injuries units, and out-of-hours general practice), the effects on A&E attendance, patient outcomes, and cost were inconclusive.
  
  
  CONCLUSIONS
  Studies showed a negligible effect on A&E attendance for all interventions; data on patient outcomes and cost-effectiveness are limited. There is an urgent need to examine all aspects of primary care service interventions that aim to reduce inappropriate A&E attendance.
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London.
authors.forename: Sharif A
authors.initials: SA
authors.lastname: Ismail
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London.
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Gibbons
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London.
authors.forename: Shamini
authors.initials: S
authors.lastname: Gnani
mesh_terms: D039602:After-Hours Care / Q000191:economics / Q000706:statistics & numerical data; D000553:Ambulatory Care / Q000191:economics / Q000706:statistics & numerical data; D003151:Community Health Centers / Q000191:economics / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics / Q000706:statistics & numerical data*; D058006:General Practice / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D009722:Nurse Practitioners / Q000191:economics / Q000706:statistics & numerical data; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000191:economics / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D019114:Remote Consultation / Q000191:economics / Q000706:statistics & numerical data; D013689:Telephone / Q000191:economics / Q000706:statistics & numerical data; D014218:Triage / Q000191:economics / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000191:economics / Q000706:statistics & numerical data*