Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis.
Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.



Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care.



The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.
Manchester Centre for Health Economics, University of Manchester, Manchester, United Kingdom.
William
W
Whittaker
Manchester Centre for Health Economics, University of Manchester, Manchester, United Kingdom.
Laura
L
Anselmi
Manchester Centre for Health Economics, University of Manchester, Manchester, United Kingdom.
Søren Rud
0000-0002-6608-7132
SR
Kristensen
Manchester Centre for Health Economics, University of Manchester, Manchester, United Kingdom.
Yiu-Shing
YS
Lau
Alliance Manchester Business School, University of Manchester, Manchester, United Kingdom.
Simon
0000-0001-9142-2791
S
Bailey
NIHR School for Primary Care Research Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.
Peter
P
Bower
National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester, University of Manchester, Manchester, United Kingdom.
Katherine
K
Checkland
National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester, University of Manchester, Manchester, United Kingdom.
Rebecca
R
Elvey
National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
Katy
0000-0001-6839-2598
K
Rothwell
NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.
Jonathan
J
Stokes
Alliance Manchester Business School, University of Manchester, Manchester, United Kingdom.
Damian
0000-0002-9292-5945
D
Hodgson
D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004739:England; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D011320:Primary Health Care / Q000706:statistics & numerical data*