Do out-of-hours general practitioner services and emergency departments cost more by collaborating or by working separately? A cost analysisSjoerd Broekman 1 , Elisabeth Van Gils-Van Rooij 2 , Berthold Meijboom 2 , Dingenus De Bakker 1 2 , Christoffel Yzermans 1
1 Netherlands Institute for Health Services Research, The Netherlands
2 Tilburg University Tranzo Scientific Centre for Care and Welfare, Tilburg, The Netherlands
Correspondence to: Sjoerd Broekman, Netherlands Institute for Health Services Research, 3513CR, Utrecht, The Netherlands. Email: firstname.lastname@example.org
Journal of Primary Health Care 9(3) 212-219 https://doi.org/10.1071/HC17015
Published: 25 September 2017
Journal Compilation © Royal New Zealand College of General Practitioners 2017.
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
INTRODUCTION: In the Netherlands, general practitioners (GPs) and emergency departments (EDs) collaborate increasingly in urgent care collaborations (UCCs) in which the two services share one combined entrance and joint triage.
AIM: The objective of this study is to determine if UCCs are cost-effective compared to the usual care setting where out-of-hours GP services and EDs work separately.
METHODS: This observational study compared UCCs with the usual care setting on costs by performing linear regression analyses. These costs were also combined with two performance indicators: level of patient satisfaction and the length of stay. A non-parametric bootstrap (resampling) method was performed in order to analyze the cost-effect pairs.
RESULTS: During the study period, 122,061 patients visited EDs and the out-of-hours GP services. Total mean costs per episode were substantially higher in UCCs: ?480 versus ?392 respectively. In this study, two factors that contributed to higher costs in UCCs compared to usual care were identified. First, there was a higher proportion of GP consultations instead of cheaper medical advice for self-care in UCCs. Second, in UCCs there were more often double costs per episode, as more patients were referred to an ED after triage or consulting GP services. The cost-effectiveness analyses show that UCCs were not dominant on cost-effectiveness compared to the usual care setting.
DISCUSSION: A substitution of, often self-referring, patients from EDs to GP services does not result in lower costs to society, a shorter length of stay or a higher level of patient satisfaction.
KEYWORDS: Urgent Care Collaboration; GP services; ED visits; costs
References Huibers L, Thijssen W, Koetsenruijter J, et al. GP cooperative and emergency department: an exploration of patient flows. J Eval Clin Pract. 2013; 19 243–9.
 Giesen P, Franssen E, Mokkink H, et al. Patients either contacting a general practice cooperative or accident and emergency department out of hours: a comparison. Emerg Med J. 2006; 23 731–4.
| 1:STN:280:DC%2BD28vpsVKqtA%3D%3D&md5=5664467b13164f0921fa09fb46cdec38CAS |
 Lee A, Lau FL, Hazlett CB, et al. Factors associated with non-urgent utilization of Accident and Emergency services: a case-control study in Hong Kong. Soc Sci Med. 2000; 51 1075–85.
| 1:STN:280:DC%2BD3cvltVCisg%3D%3D&md5=0ed246d2fa7f3a02e2391187acba8518CAS |
 Moll van Charante EP, ter Riet G, Bindels P. Self-referrals to the A8E department during out-of-hours: patients’ motives and characteristics. Patient Educ Couns. 2008; 70 256–65.
 Ward P, Huddy J, Hargreaves S, et al. Primary care in London: an evaluation of general practitioners working in an inner city accident and emergency department. J Accid Emerg Med. 1996; 13 11–5.
| 1:STN:280:DyaK28vhvVCgsw%3D%3D&md5=a3afc9b6a0ebed9423eb543cd7513dc5CAS |
 Dale J, Green J, Reid F, Glucksman E. Primary care in the accident and emergency department: I. Prospective identification of patients. BMJ. 1995; 311 423–6.
| 1:STN:280:DyaK2Mzmsl2nsw%3D%3D&md5=0eb9aff7fb7291666b65afcc73b096aaCAS |
 Derlet R, Richards J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med. 2001; 8 151–5.
| 1:STN:280:DC%2BD3M3gtlOnug%3D%3D&md5=e1bd688c73c8a20f92cb37ff074baa95CAS |
 Van Erkelens JA, Van Galen MS, Van Gorp T, et al. Zorgthermometer [Health care monitor]. Vooruitblik 2014 [Prospective 2014] [serial on the Internet]. 2013; 18. [cited 2016 June 9]. Available from: http://www.vektis.nl/downloads/Publicaties/2013/Zorgthermometer%20-%20Vooruitblik%202014/index.html#34/z
 Jaarsma-van Leeuwen I, Hammacher ER, Hirsch R, Janssens M. Patiënten zonder verwijzing op de afdeling Spoedeisende Hulp: patiëntkarakteristieken en motieven Ned Tijdschr Geneeskd. 2000; 144 428–31. [Patients without referral treated in the emergency room: patient characteristics and motives]
| 1:STN:280:DC%2BD3c7osVClsw%3D%3D&md5=eee1592a9e83c775e6281206ef052611CAS |
 Ijzermans CJ, Mentink S, Klaphake LM, et al. Contacten buiten de kantooruren: klachten gepresenteerd aan de huisarts en aan de Spoedeisende Hulp Ned Tijdschr Geneeskd. 2002; 146 1413–7. [Contacts outside of office hours: complaints presented to the general practitioner and to the emergency department]
| 1:STN:280:DC%2BD38vitVagtA%3D%3D&md5=e7c3bea0502d8efb83c9d0b2be0dbb82CAS |
 Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica. 2009; 25 7–28.
 NZa. Werken met DBC's [Working with Diagnostic Treatment Combinations]. Utrecht: Nederlandse Zorgautoriteit; 2015. [cited 2015 June 09]. Available from: http://werkenmetdbcs.nza.nl/dbc-systematiek.
 Schäfer W, Kroneman M, Boerma W, et al. Health system review. Health Syst Transit. 2010; 12 v–xxvii.
 Boeke AJ, van Randwijck-Jacobze ME, de Lange-Klerk EM, et al. Effectiveness of GPs in accident and emergency departments. Br J Gen Pract. 2010; 60 e378–84.
 Bosmans JE, Boeke AJ, van Randwijck-Jacobze ME, et al. Addition of a general practitioner to the accident and emergency department: a cost-effective innovation in emergency care. Emerg Med J. 2012; 29 192–6.
 Dale J, Lang H, Roberts JA, et al. Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners, senior house officers, and registrars. BMJ. 1996; 312 1340–4.
| 1:STN:280:DyaK283jtlCnsQ%3D%3D&md5=f60ebdfe70660b536be547e27a273aebCAS |
 De Huisartsenpost VHN. Armslag voor een goed eerstelijns loket. 2015. In: InEen, VHN. Utrecht: InEen. [cited 2016 June 09]. Available from: http://docplayer.nl/10082989-De-huisartsenpost-armslag-voor-een-goed-eerstelijns-loket.html
 Giesbers S. Spoedeisende hulp en huisartsenzorg: een kostenanalyse [Emergency department and GP care: a cost analysis]. Nijmegen: UMC St Radboud; 2010.
 van Uden CJ, Ament AJ, Voss GB, et al. Out-of-hours primary care. Implications of organisation on costs. BMC Fam Pract. 2006; 7 29
 van Gils-van Rooij ESJ, Yzermans CJ, Broekman SM, Meijboom BR, De Bakker DH. Out-of-hours care collaboration between general practitioners and hospital emergency departments in the Netherlands. J Am Board Fam Med. 2015; 28 8
 Van Gils-van Rooij ESJ. The paradox of urgent care collaborations: a multi perspective study of cooperating emergency departments and general practitioners Amersfoort: Wilco. Doctoral thesis, Tilburg University, Tilburg, The Netherlands; 2016. Available from: https://pure.uvt.nl/ws/files/12403683/Van_Rooij_The_paradox_29_06_2016.pdf.
 van Ierland Y, van Veen M, Huibers L, et al. Validity of telephone and physical triage in emergency care: the Netherlands Triage System. Fam Pract. 2011; 28 334–41.
 van der Wulp I. Reliability and validity of emergency department triage systems. Utrecht: Universiteit Utrecht; 2010.
 Delnoij DM, Rademakers JJ, Groenewegen PP. The Dutch consumer quality index: an example of stakeholder involvement in indicator development. BMC Health Serv Res. 2010; 10 88
 Black WC. The CE plane: a graphic representation of cost-effectiveness. Med Decis Making. 1990; 10 212–4.
| 1:STN:280:DyaK3czhvVaiug%3D%3D&md5=a222dee40b8fc8f24b1914fe6627d7feCAS |
 Hassaart F. Incentives in the Diagnosis Treatment Combination payment system for specialist medical care. Maastricht: Maastricht University; 2011.
 Dafny LS. How do hospitals respond to price changes? Am Econ Rev. 2005; 95 22