ARTICLEPEDIATRICS Volume 137 , number 2 , February 2016 :e 20151492

Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UKElizabeth Cecil, MSc,a Alex Bottle, PhD,a Thomas E. Cowling, MPH,a Azeem Majeed, MD,a Ingrid Wolfe, MD,b Sonia Saxena, MDa

abstractBACKGROUND AND OBJECTIVE: Demand for unplanned hospital services is rising, and children are

frequent users, especially where access to primary care is poor. In England, universal health

care coverage entitles parents to see a general practitioner (GP) for first-contact care.

However, access to GP appointments is variable, and few patients can see their own regular

GP out of hours (OOH). The goal of this study explored the association between access to

GPs , emergency department (ED) visits and short hospitalizations (<2 days) in children in

England.

METHODS: ED visit and short hospitalization rates were investigated in 9.5 million children

aged <15 years registered with English family practices between April 2011 and March

2012 by using administrative hospital data. Six access categories ranked all practices

according to patients’ reported ability to schedule GP appointments; from national GP

Patient Survey data. GP consulting hours were 8:00 AM to 6:30 PM on weekdays.

RESULTS: There were 3 074 616 ED visits (56% OOH) and 470 752 short hospitalizations over

the 12 months studied. Children registered with practices in the highest access group

compared with the lowest were 9% less likely to visit an ED (adjusted rate ratio: 0.91 [95%

confidence interval: 0.89–93]), particularly OOH compared with consulting hours (10% vs

7%). Children in the highest access groups were equally likely to be admitted for a short

stay.

CONCLUSIONS: Increasing GP accessibility might alleviate the burden of ED visits from children,

particularly during peak times OOH. Short hospitalizations may be more sensitive to other

aspects of health systems.

aDepartment of Primary Care and Public Health, Imperial College London, London, United Kingdom; and bDepartment of Primary Care and Public Health Sciences, King’s College London, London, United Kingdom

Ms Cecil contributed to the conception and design of the study, conducted the analysis,

participated in interpreting the data, drafted the initial manuscript, and wrote the fi nal

manuscript as submitted; Dr Bottle contributed to the conception and design of the study,

provided statistical advice, participated in interpreting the data, and helped to revise drafts of

the manuscript; Dr Saxena and Mr Cowling contributed to the conception and design of the study,

participated in interpreting the data, and helped revise drafts of the manuscript; and Drs Majeed

and Wolfe participated in interpreting the data and helped to revise drafts of the manuscript. All

authors approved the fi nal manuscript as submitted and agree to be accountable for all aspects

of the work.

DOI: 10.1542/peds.2015-1492

Accepted for publication Nov 18, 2015

Address correspondence to Elizabeth Cecil, MSc, Department of Primary Care and Public Health,

Imperial College London Charing Cross Campus, W6 8RP, UK. E-mail: e.cecil@imperial.ac.uk

To cite: Cecil E, Bottle A, Cowling TE, et al. Primary Care Access, Emergency

Department Visits, and Unplanned Short Hospitalizations in the UK. Pediatrics.

2016;137(2):e20151492

WHAT’S KNOWN ON THIS SUBJECT: Rising use of

unplanned hospital services is becoming fi nancially

unsustainable, and health planners are searching

for solutions to alleviate the strain on emergency

departments (EDs). Children’s use of unplanned

services may be a marker of poor access to primary

care.

WHAT THIS STUDY ADDS: Children registered with

more accessible family practices are less likely to visit

EDs but no more likely to have a short hospitalization.

Increasing access might reduce children’s ED visits,

particularly during peak times. Reducing short

hospitalizations may require additional interventions.

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CECIL et al

Internationally, health systems are

challenged by increasing demand

and diminishing funds,1,2 while the

epidemiologic transition in children

toward long-term conditions makes

the need to strengthen health

systems increasingly urgent.3 The

United Kingdom has a publicly

funded and universally accessible

National Health Service (NHS),

whereby 98% of children are

registered with a primary care

physician or general practitioner

(GP) whom they consult as first

contact for health care needs.4

Access to primary care is crucial for

containing the use of emergency

departments (ED) and unplanned

hospitalization5,6; many countries

look to the NHS as an exemplar of

equitable and cost-effective primary

care. However, nearly one-half of

the NHS budget is spent on acute

and emergency care,7 and spending

is becoming unsustainable. Up to

40% of ED visits are believed to

be “inappropriate” and potentially

treatable in primary care,8 most

commonly among very young

children.9

Two-thirds of all unplanned

hospitalizations in children are for a

short stay (<2 days) for mostly minor

conditions, which, it has been argued,

may be more appropriately managed

in the community.10 Certainly,

short hospitalizations for chronic

conditions have been positively

associated with withdrawal of

primary care.11 Ambulatory care–

sensitive (ACS) conditions are

defined as conditions for which

hospitalization can be avoided by

responsive and preventive primary

care. Studies of ACS hospitalizations

in children have used pediatric

quality indicators12,13 developed

in the United States and the United

Kingdom such as those of the

Agency for Healthcare Research and

Quality (AHRQ).14 These indicators

relate to limited specific conditions

(eg, urinary tract infection,

gastroenteritis, asthma, diabetes)

accounting for <10% of highly

frequent causes of hospitalization

among children.11 In addition, in the

United Kingdom, pediatric diabetes is

managed by specialist physicians and

not by GPs. Hence, this smaller subset

of conditions may underestimate the

magnitude to which primary care

accessibility could have an impact

on health system pressures. The

use of broader composite measures

overcomes these limitations and

reduces the risks of coding bias of

specific conditions.

The goal of the present study was to

investigate the association between

GP access and use of unplanned

hospital service. We hypothesized

that children registered with

practices whose patients report

better access (according to the GP

Patient Survey [GPPS]) had fewer ED

visits, fewer short hospitalizations

for chronic conditions, and fewer

hospitalizations for ACS conditions.

METHODS

This cross-sectional, population-

based study was conducted in

children aged <15 years and

registered with family practices in

England between April 1, 2011, and

March 31, 2012.

Outcome Measures

The administrative health data set

Hospital Episode Statistics (HES) was

used, which contains records of ED

visits and inpatient hospitalizations

to all NHS hospitals in England.15

Our primary outcomes were

adjusted rates for ED visits, short

hospitalizations, and AHRQ-defined

ACS hospitalizations. We calculated

rates as the number of events

divided by the registered population

of children in each practice and

expressed as rates per 1000 children.

Practice populations were provided

by The NHS Health and Social Care

Information Centre.16 A total of

95 practices (1%) in which the

total practice population was <500

were excluded because these were

likely to include atypical practice

populations.17

Data were extracted related to ED

2011–2012 visits from the HES

accident and emergency (A&E)

data set. Four types of A&E services

are included in these data: (1) a

consultant-led 24-hour service

with full resuscitation facilities; (2)

single specialty service; (3) other

A&E service; and (4) NHS walk-in

center.18 The type of A&E service

was unknown for 3.5% of visits.

We included all visits to EDs, type

1 as well as type 3, because these

include urgent care centers that are

commonly co-located within English

EDs.19 An ED visit on weekends or

public holidays was defined as being

out of hours (OOH) or when arrival

time was between 6:30 PM and 8:00

AM on weekdays (Fig 1).

Using HES inpatient data, short

hospitalizations were defined as

a length of stay <2 days (0 or 1

day) and no readmission within

28 days (the latter may reflect

failure of hospital care).10,20

Within short hospitalizations, 3

broad diagnosis categories were

identified: infectious illness,

chronic conditions, and injury.11

Short hospitalizations for chronic

conditions are positively associated

with primary care withdrawal,

whereas short hospitalizations for

injury are not considered ACS. Total

unplanned hospitalization rates were

investigated for 4 previously defined

ACS conditions in children14,21:

asthma, diabetes, gastroenteritis (by

using the broader classification of

“intestinal infection”), and urinary

tract infection.

We have reported a complete list

of codes and algorithms for the

outcomes short hospitalizations

and ACS conditions (Supplemental

Data) in accordance with the

Reporting of Studies Conducted using

Observational Routinely-Collected

Health Data statement.22 Long

hospitalizations (ie, those lasting ≥2

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PEDIATRICS Volume 137 , number 2 , February 2016

days) were considered as “moderate”

or “serious” conditions.

Measure of Primary Care Access

The measure of primary care access

was derived from the 2011–2012

GPPS, an annual national survey that

assesses patients’ experiences of

the access and quality of care they

receive from their GP.23 The GPPS

is well established, covering all UK

practices,24 and GPPS-derived access

measures have been found to be

reliable.25 Practices were classified

into 6 groups of access according

to the proportion of patients who

reported they were “able to get an

appointment to see or speak to a

GP or nurse on their last attempt.”

Patients were instructed to answer

the question only if such an attempt

had been made. The lowest access

group was <75% access; groups

thereafter increased by 5% up to

95% to 100%.

Control Variables

We controlled for practice

deprivation and urban/rural

profile. English Indices of Multiple

Deprivation scores were grouped

according to quintiles.26 Data on

urban/rural profile were supplied

by The NHS Health and Social Care

Information Centre. Because elderly

patients typically have greater health

care needs (potentially increasing GP

workload and reducing appointment

availability), we adjusted for

the percentage of the registered

population who were aged ≥65 years.

Less than 0.1% of data were missing

control variables.

Statistical Methods

A negative binomial regression

model was applied, accounting

for overdispersion of the outcome

variables, to explore the association

between practice-level, patient-

reported access and ED visit/

hospitalization rates. We adjusted for

the confounders described earlier. An

association with a P value <.01 was

regarded as statistically significant

and compared with a full model to

check for bias in the coefficients. The

analysis was also stratified according

to whether an ED visit occurred OOH.

The access variable was included as

a continuous variable, its coefficient

representing the log rate ratio (RR)

of a 5% increase in access. From

the coefficient, the RR between the

highest and lowest access group

were calculated by multiplying the

coefficient by 5 and exponentiating

the result.

Assuming a causal association

between GP access and visits in

children, the number of visits was

estimated that could potentially be

avoided if access in the 3 lowest

groups was improved to a minimum

threshold of 85% as:

No. Visits (<75% access) ×

(RR(<75%vs85-90% access)−1) + No.

Visits(75-80% access) × (RR(75-80%vs85-90%

access)−1) + No. Visits (80-85% access) ×

(RR(80-85%vs85-90% access)−1)

Stata SE version 11 (Stata Corp,

College Station, TX) was used for the

data analysis.

RESULTS

From April 1, 2011, to March 31,

2012, there were 3 074 616 ED

visits and 616 229 unplanned

hospitalizations among 9 456 859

children aged <15 years registered

with 8035 English practices. A

3

FIGURE 1Flowchart outlining derivation of outcomes from hospital statistics data. ID, identifi er.

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CECIL et al

total of 1 722 899 ED visits (57%)

were OOH, and 470 752 unplanned

hospitalizations (76%) were for a

short stay (Fig 1).

Family Practice Characteristics

Patient-reported access was high

(median: 88% [interquartile range

(IQR): 83%–92%]). Practices in

the highest access group were

more likely to be in affluent areas;

34% (285 of 829) were in the least

deprived group, whereas only

7.7% (64 of 829) were in the most

deprived group (P < .001) (Table

1). Practices in the highest access

group were less likely to be in urban

areas (64.8% [537 of 829] vs 98.8%

[409 of 414] in the lowest access

group). Practices in the highest

access group had a lower proportion

of registered children (median:

16.0% vs 21.2%, respectively) and a

greater proportion of elderly patients

(median: 18.8% vs 8.8%) compared

with those in the lowest access group.

ED Visit Rates

ED visits were more frequent in

younger children. One in 3 children

aged <5 years visited an ED at least

once in 2011–2012 (959 502 of

3 304 990), whereas the proportion

of children aged 5 to 14 years who

visited an ED was 17% (1 043 252

of 6 153 009). Rates of ED visits on

weekdays ranged from a low point of

5 children per million at 5:00 AM to a

peak of 84 children at 6:00 PM. There

was no 6:00 PM peak at weekends.

Practices in the highest access group

had a lower proportion of visits

OOH (median: 55.4% [IQR: 51.4%–

58.9%]) compared with 59.4% (IQR:

55.8%–63.5%) in practices with the

lowest access group (Table 1).

The median practice ED visit rate

was 323 visits per 1000 children

(IQR: 251–403) (Table 1). Children

registered with practices in the

highest access group had a 29%

lower crude rate of ED visits

compared with children registered

with practices in the lowest access

group (RR: 0.71 [95% confidence

interval (CI): 0.89–0.93]) (Table 2).

Younger children, boys, and those

living in a deprived or urban area

were all more likely to visit EDs.

Children registered with practices

in the highest access group had a

9% lower adjusted rate of ED visits

compared with the lowest group

4

TABLE 1 Practice-Level ED Visit Rates, Hospitalization Rates, and Demographic Characteristics According to Patient-Reported GP Access

Variable Patient-Reported Access

<75% (n = 414) 75% to 80% (n =

662)

80% to 85% (n =

1341)

85% to 90% (n =

2352)

90% to 95% (n =

2437)

95% to 100% (n =

829)

Crude ED visit rates 383 (317–460) 373 (296–444) 350 (277–428) 327 (257–405) 297 (234–376) 277 (218–346)

Crude unplanned

hospitalization rates

Total 67.0 (48.1–88.0) 62.4 (47.5–82.6) 62.7 (46.6–84.7) 61.8 (46.3–80.7) 60.9 (46.1–78.2) 55.5 (42.7–74.3)

Short stay 48.9 (32.9–67.7) 45.7 (31.8–63.6) 47.3 (31.1–66.9) 47.0 (30.9–64.7) 47.1 (32.5–62.7) 42.6 (30.6–57.8)

Long stay 14.0 (10.1–18.9) 13.8 (10.5–17.8) 13.9 (10.6–17.7) 12.9 (9.7–16.7) 12.3 (9.2–15.9) 11.4 (8.0–15.2)

Crude short hospitalization

rates

Chronic condition 19.6 (14.3–25.8) 18.2 (13.1–23.9) 17.7 (12.8–24.3) 17.2 (12.1–22.7) 16.3 (11.7–22.0) 15.1 (10.4–20.4)

Infectious disease 31.6 (20.1–42.9) 27.9 (19.6–39.5) 28.6 (19.5–41.0) 27.7 (19.2–39.0) 27.7 (19.0–37.9) 25.1 (17.0–35.3)

Injury 9.1 (6.7–12.8) 9.3 (6.5–12.2) 9.7 (7.0–12.8) 9.7 (7.1–12.8) 9.6 (7.0–12.5) 9.3 (6.8–13.0)

Crude ACS condition

hospitalization rates

Diabetes 0.0 (0.0–0.7) 0.0 (0.0–0.8) 0.0 (0.0–0.7) 0.0 (0.0–0.7) 0.0 (0.0–0.7) 0.0 (0.0–0.6)

Asthma 2.4 (0.9–4.4) 2.0 (0.8–3.6) 1.8 (0.7–3.2) 1.5 (0.5–2.9) 1.3 (0.0–2.6) 0.9 (0.0–2.3)

Urinary tract infection 0.8 (0.0–1.8) 0.8 (0.0–1.6) 0.8 (0.0–1.7) 0.8 (0.0–1.6) 0.7 (0.0–1.6) 0.0 (0.0–1.5)

Intestinal infection 2.2 (0.8–3.9) 2.0 (0.8–4.0) 2.0 (0.8–3.9) 2.0 (0.7–3.7) 2.0 (0.7–3.6) 1.7 (0.0–3.5)

% ED visits OOH 59.4 (55.8–63.5) 58.2 (54.5–61.9) 57.1 (53.5–60.9) 56.3 (52.6–60.2) 55.6 (51.8–59.4) 55.4 (51.4–58.9)

% GP population aged <15 y 21.2 (17.7–25.7) 18.5 (16.1–22.0) 17.9 (15.9–20.3) 17.0 (15.2–19.1) 16.4 (14.8–18.1) 16.0 (14.2–17.8)

% GP population aged

≥65 ye

8.8 (6.0–12.4) 11.8 (8.3–15.8) 14.0 (10.1–17.4) 15.9 (12.3–19.1) 17.6 (14.3–20.9) 18.8 (15.7–22.4)

Deprivation, n (%)a

1 (least deprived) 8 (1.9) 29 (4.4) 143 (10.7) 473 (20.1) 664 (27.3) 285 (34.4)

2 14 (3.4) 76 (11.5) 183 (13.7) 486 (20.7) 618 (25.4) 239 (28.8)

3 65 (15.7) 131 (19.8) 289 (21.6) 490 (20.9) 502 (20.6) 133 (16.0)

4 92 (22.2) 173 (26.2) 355 (26.5) 495 (21.1) 372 (15.3) 108 (13.0)

5 (most deprived) 235 (56.8) 252 (38.1) 368 (27.5) 405 (17.2) 279 (11.5) 64 (7.7)

Urban 409 (98.8) 636 (96.1) 1251 (93.3) 2075 (88.2) 1889 (77.5) 537 (64.8)

Data are presented as median (IQR) unless otherwise indicated. The data are of all ED visits and unplanned hospitalizations of children aged <15 years in England between April 2011 and

March 2012. Practice rates are per 1000 child population. Short hospitalizations are unplanned hospitalizations lasting <2 days; long hospitalizations are unplanned hospitalizations for

≥2 days. Patient-reported access is the percentage of family practice patients, responding to the GPPS,27 who were “able to get an appointment to see or speak to a GP or nurse on their

last attempt” categorized into 6 groups; <75% represents the practices with the lowest reported access and 95% to 100% the highest reported access.a Deprivation data are the practice Index of Multiple Deprivation scores (2010)28 categorized into 5 groups according to quintiles.

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PEDIATRICS Volume 137 , number 2 , February 2016

(RR: 0.91 [95% CI: 0.89–0.93]).

Access was more strongly associated

with ED visits OOH (RR: 0.90

[95% CI: 0.88–0.92]), whereas for

in-hours, the RR was 0.93 (95% CI:

0.91–0.96). Improving access to 85%

would potentially have prevented

33 000 (1.1%) visits in 2011–2012

(26 000–41 000).

The proportion of young children

visiting an ED increased OOH. A child

aged <5 years was 1.5 times more

likely than a child aged 5 to 14 years

to visit an ED in hours but twice as

likely OOH. The proportion of elderly

patients registered with a practice

was not associated with ED visit rates

among children.

Short Hospitalization Rates

Children registered at practices in the

highest access group had lower crude

short hospitalization rates compared

with those in the lowest access group

(RR: 0.97 [95% CI: 0.93–1.00]). The

association reversed when adjusted

for deprivation (RR: 1.10 [95% CI:

1.06–1.14]). However, there was

no association when rates were

adjusted for all confounding factors

(RR: 1.01 [95% CI: 0.98–1.03]) (Table

3). Younger children, boys, and

practices in deprived areas or urban

areas were risk factors for short

hospitalizations. Practices with a

higher proportion of elderly patients

had more GP-referred (but not self-

referred) short hospitalizations for

children.

Children registered at practices in

the highest access group had 8%

lower adjusted short hospitalization

rates for chronic conditions (RR: 0.92

[95% CI: 0.89–0.96]) and 10% higher

adjusted short hospitalization rates

for injury (Table 3). There was no

association between patient-reported

access and short hospitalizations for

infectious illness.

ACS Hospitalization Rates

Children registered at practices in the

highest access group had 21% lower

adjusted asthma hospitalization rates

(RR: 0.79 [95% CI: 0.74–0.85]) than

children registered in the lowest

access group (Table 3). There was

borderline evidence of a negative

association between access and

diabetes hospitalization rates (RR:

0.87 [95% CI: 0.76–1.00]). There

was no evidence of an association

between access and hospitalization

5

TABLE 2 ED Visit and Unplanned Hospitalization RRs: Regression Analysis

Variable Total ED Visits Total Unplanned Hospitalizations

RR (95% CI) RR (95% CI)

Crude Adjusted Crude Adjusted

Access (95%–100% vs <75%)a 0.71 (0.69–0.73) 0.91 (0.89–0.93) 0.93 (0.90–0.96) 0.99 (0.97–1.02)

Gender (girls versus boys) 0.81 (0.80–0.82) 0.81 (0.80–0.82) 0.80 (0.78–0.81) 0.81 (0.80–0.81)

Age, years (5–15 vs 0–4) 0.57 (0.56–0.57) 0.57 (0.57–0.58) 0.27 (0.26–0.27) 0.27 (0.27–0.27)

Deprivationb

1 (least deprived) 1 1 1 1

2 1.13 (1.11–1.15) 1.11 (1.09–1.13) 1.13 (1.10–1.16) 1.13 (1.11–1.14)

3 1.27 (1.25–1.30) 1.21 (1.19–1.23) 1.21 (1.18–1.25) 1.25 (1.23–1.27)

4 1.43 (1.41–1.46) 1.33 (1.31–1.35) 1.30 (1.26–1.33) 1.37 (1.35–1.39)

5 (most deprived) 1.55 (1.52–1.58) 1.41 (1.39–1.43) 1.38 (1.34–1.42) 1.52 (1.50–1.55)

Locality (urban versus rural) 1.35 (1.33–1.37) 1.12 (1.10–1.14) 1.08 (1.05–1.10)

% Population aged ≥65 y 0.98 (0.98–0.98) 1.00 (1.00–1.01) 1.02 (1.02–1.02)

The data are of ED visits and all unplanned hospitalizations of children aged <15 years in England between April 2011 and March 2012.a Patient-reported access is the percentage of family practice patients, responding to the GPPS,25 who were “able to get an appointment to see or speak to a GP or nurse on their last

attempt” categorized into 6 groups; <75% represents the practices with the lowest reported access and 95% to 100% the highest reported access.b Deprivation data are the practice Index of Multiple Deprivation scores (2010)28 categorized into 5 groups according to quintiles; 1 represents practices with the least deprived post codes

and 5 represents the most deprived post codes.

TABLE 3 Unplanned Hospitalization RRs Comparing 95% to 100% Patient-Reported Access With <75%:

Regression Analysis

Variable RR (95% CI)

Crude Adjusted

Unplanned hospitalizations

Short staya 0.97 (0.93–1.00) 1.01 (0.98–1.03)

Long stayb 0.83 (0.80–0.86) 0.96 (0.94–0.99)

Short hospitalizations composite categoriesc

Chronic condition 0.87 (0.83–0.90) 0.92 (0.89–0.96)

Infectious disease 0.98 (0.93–1.03) 1.00 (0.96–1.03)

Injury 1.03 (0.99–1.06) 1.10 (1.06–1.14)

ACS conditions

Diabetes 0.86 (0.76–0.98) 0.87 (0.76–1.00)

Asthma 0.45 (0.42–0.48) 0.79 (0.74–0.85)

Urinary tract infection 0.76 (0.70–0.83) 1.03 (0.94–1.13)

Intestinal infection 0.76 (0.71–0.81) 0.99 (0.93–1.05)

The data are of ED visits and all unplanned hospitalizations of children aged <15 years in England between April 2011

and March 2012. Patient-reported access is the percentage of family practice patients, responding to the GPPS,25 who

were “able to get an appointment to see or speak to a GP or nurse on their last attempt” categorized into 6 groups; <75%

represents the practices with the lowest reported access and 95% to 100% the highest reported access.a Defi ned as <2 days.b Defi ned as ≥2 days.c The primary reason (diagnosis) for the hospitalizations was grouped into a broad composite category.

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CECIL et al

rates for urinary tract infections or

intestinal infection.

Long Hospitalization Rates

Children registered at practices in the

highest access group had 4% lower

adjusted long hospitalization rates

(RR: 0.96 [95% CI: 0.94–0.99]) than

children registered in the lowest

access group (Table 3).

DISCUSSION

Main Findings

Our national study of all 9.5 million

children registered with 8035

family practices in England found

that children registered in practices

within the highest access group

compared with those in the lowest

access group were 7% less likely to

visit EDs during GP consulting hours

and 10% less likely OOH. Fifty-six

percent of all ED visits occurred OOH,

and rates peaked after school hours.

Overall, 76% of unplanned

hospitalizations were short, but

there was no evidence that they

were related to GP access. However,

children registered with more

accessible practices had lower

short hospitalization rates for

chronic conditions and ACS chronic

conditions.

Study Limitations

The strengths of our study include its

size, national population coverage,

and high level of completeness of

HES in patient data.27,29 However,

the quality and coverage of A&E data

are reportedly less reliable.28 We

found that the number of ED visits

which resulted in a hospitalization

were comparable to the number

of hospitalizations (inpatient

data) which originated from an

“A&E service.” In common with all

administrative databases, discharge

coding limitations within HES exist,30

but improvements in the past decade

mean that they are robust enough

to support their use in research.

Potential biases were minimized by

the use of broad diagnosis categories.

Because we lacked disease-

specific denominators, registered

populations broken down by age,

gender, and deprivation were used as

proxies. These factors are all strong

determinants of chronic disease

prevalence in children but are not

the only ones. Our cross-sectional,

population-based study design has

inherent limitations. We can only

infer associations and only then

for the population rather than for

individual patients. The comparison

groups in this study were based on

the reported ability of a patient to

schedule an appointment according

to the GPPS, and questionnaires are

susceptible to bias. However, the

GPPS employs a weighting strategy

to control for nonresponse bias,31

and responses reflect overall scores

regardless of the response rate.25 The

questionnaire does not differentiate

between responses of patients and

parents for their children; therefore,

assuming that GP access between

these population groups are similar

may introduce some bias. There

is a risk of residual confounding

especially because there were

significant differences in patient

characteristics between practices

with different accessibility. One

example is ethnicity, whereby health

service use differs between ethnic

groups32; however, we consider the

effects to be small.

Findings in Relation to Previous Studies

Our findings of an association

between primary care access and ED

visits are consistent with previous

studies in adults6,33 and children,34

as is the positive association between

deprivation and ED visits.6,33,35

Although previous studies found

negative associations between access

and unplanned hospitalizations,36,37

we did not. However, these studies

investigated specific conditions that

were targeted by financial health

incentives, which were in adult

populations, and the effect sizes

reported were small. Our study

focusing on children extends these

previous studies by examining

the associations of access with the

timing of ED visits in-hours and

OOH and broader groups of short

hospitalizations.

Implications and Future Research

Our estimation that >30 000 excess

children’s visits (1.1%) could have

been avoided by improving GP

access in below-average practices

illustrates the potential that investing

in primary care could have on

alleviating the strain on EDs.

The UK government is considering

health policies that will extend 7-day

access from some local schemes

nationally in a new deal set to

GPs.38 This reform will have major

implications for the GP workforce

and UK health budgets.39 However,

in the last few years, GPs have come

under considerable pressure to

manage patients’ needs on smaller

budgets and in an increasingly

demanding environment.40 Services

are stretched, and capacities must

be expanded to cope with demand.

Our findings highlight the variability

of ED visits and suggest that some

practice areas are likely to require

more investment, particularly those

with a higher registered population

of young children and in deprived

and urban areas. We suggest that

additional resources should be found

to evaluate the potential of children’s

open access surgeries at a convenient

time for parents and their child’s

health care needs, ideally between

4:00 PM and 7:00 PM. However, access

to health care is multifaceted41;

therefore, although increasing

availability of GP appointments

should be a priority, it should not

be at the expense of continuity of

care.42,43 The fact that reported

GP access is associated with ED

visits but not short hospitalizations

illustrates the effectiveness of the

ED interface regardless of GP access.

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PEDIATRICS Volume 137 , number 2 , February 2016

However, the practice of visiting

EDs for providing primary care is

an inefficient use of that service and

could detract resources from more

seriously ill children. The association

found between elderly practice

population and GP-referred short

hospitalizations in children may

reflect a lower threshold among some

GPs, who are used to treating more

elderly patients, to refer children

to hospital. We feel this finding

warrants more investigation

Our study found that children

registered with more accessible

practices were less likely to experience

a short hospitalization for a chronic

condition after controlling for

confounding factors. This finding

highlights the importance of

primary care in preventing adverse

outcomes for the increasing number

of children with chronic conditions.3

Although effect sizes were bigger for

asthma admission rates (a condition

managed within primary care),

short hospitalizations for all chronic

conditions may be a more useful

indicator for ACS hospitalizations

because these admissions are more

frequent, and diagnosing asthma

in young children is difficult. The

borderline evidence of a negative

association between accessibility and

diabetes hospitalization rates may

reflect the fact that UK GPs are not

responsible for managing pediatric

diabetes. However, increasing GP

access is unlikely to stem the rising tide

of short hospitalizations, which may

be more sensitive to other factors such

as hospital and physician behavior in

admitting a child. Our research applies

to all health care systems in which

avoidable use and costs of unplanned

hospital services are of importance to

policy makers. Research is needed to

investigate the benefits of public health

incentives proactively promoting

alternatives to unplanned care,44

innovative health service models

aimed at delivering improved child

health care within the community,45

and promotion of primary care through

practice health champions.46

CONCLUSIONS

Increasing GP accessibility could

alleviate visits to EDs, particularly

OOHs at peak times (eg, after

school), thus enabling children to

access urgent care closer to home.

Improving access to primary care

is an important policy response

to health service pressures, but

investment is needed for these

changes and should be weighted

toward supporting practices in urban

or deprived areas and those who

have a larger population of registered

children where pressures are highest.

Increasing GP accessibility may

also reduce short hospitalizations

for some children with chronic

conditions; however, short

hospitalizations for other conditions

may be more sensitive to other

aspects of health systems.

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ABBREVIATIONS

A&E:  accident and emergency

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Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: Ms Cecil and Dr Saxena are funded by the National Institute for Health Research (Career Development Fellowship CDF-2011-04-048). Mr Cowling

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originally published online January 20, 2016; Pediatrics Sonia Saxena

Elizabeth Cecil, Alex Bottle, Thomas E. Cowling, Azeem Majeed, Ingrid Wolfe andHospitalizations in the UK

Primary Care Access, Emergency Department Visits, and Unplanned Short

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