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How primary and tertiary care services collaborate in urgent care delivery: an evaluation of general practice advice lines

BMC Primary Care volume 25, Article number: 406 (2024) Cite this article

Abstract

Background

To address the rising demand for urgent care and decrease hospital use, health systems are implementing different strategies to support urgent care patients (i.e. patients who would have typically been treated in hospital) in the community, such as general practitioner (GP) advice lines. The aims of this study were to: identify the support and resources GPs need to manage urgent care patients in the community; assess the need for GP advice lines by primary care services in Australia; and identify the facilitators and barriers to adoption, and strategies to support the sustainability of GP advice lines.

Methods

Qualitative study involving semi-structured interviews with GPs, hospital-based healthcare providers, consumers, and healthcare management, recruited via existing investigator networks and snowballing approach. The interviews were conducted between February and August 2023. Major themes were identified by an iterative and inductive thematic analysis.

Results

We interviewed 16 participants (median age 50, IQR 38–59). Based on the aims of the study, three themes emerged: support and resources for GPs; motivation for GP advice lines; and factors influencing the uptake and sustainability of GP advice lines. Participants reported that better communication from hospital services with GPs is critical to ensure continuity of care between tertiary and primary settings. They also noted that GP advice lines can help increase capacity to manage urgent care patients in the community by providing timely decision-support to GPs. However, a reported barrier to the uptake and ongoing use of GP advice lines was the limited hours of the service. To sustain GP advice lines, participants highlighted a need to broaden the scope of the service beyond the pandemic, conduct rigorous evaluation on health outcomes, and further digitise the service so that a tiered level of support could be provided based on risk stratification.

Conclusions

The benefits of GP advice lines are yet to be fully realised. With increasing technology sophistication, there remain opportunities to further digitise and optimise GP advice lines, whilst ensuring better integration within and across primary and tertiary care services. This is however dependent on continued financial and policy support from the government.

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Introduction

Demand for emergency and urgent care has been rising consistently worldwide, with emergency department (ED) visits increasing by as much as 3% to 6% each year [1,2,3]. An important driver for the growth in ED visits is the presentation of patients with conditions that could potentially be treated in the community [3, 4]. In Australia, between 2022 and 2023, 16% of ED visits were classified as emergencies (i.e., life-threatening conditions), 40% were classified as urgent, and the remainder were semi-urgent or non-urgent [2]. A high prevalence of lower acuity ED presentations contributes to longer waiting times and adverse outcomes for all patients, as well as higher overall healthcare costs [5].

To address the rising demand for urgent care and decrease unnecessary ED use, health systems are implementing different strategies to support urgent care patients (i.e. patients who would have typically been treated in hospital). Strategies to increase out-of-hospital urgent care capacity and improve coordination between General Practice (GP) and hospitals include virtual urgent care models such as [3, 6]: delivering digitally-enabled care remotely to patients at home (i.e. virtual care); and delivering hospital specialist advice remotely to GPs via telephone lines (i.e. GP advice lines) [7, 8]. GP advice lines are telephone hotlines that provide primary care providers with timely access to hospital specialists’ advice [9].

Existing studies of GP advice lines from Canada, the United States, France and Italy have indicated reductions in referrals, ED visits, and hospitalisations, as well as cost-savings and clinician satisfaction associated with the implementation [9,10,11,12,13,14,15]. In Australia, studies of telephone communication between GPs and hospital specialists indicate satisfaction, but low awareness and low uptake for the majority of targeted users [16, 17]. This indicates the need for in-depth evaluations of GP advice line services to identify whether and why GPs need these advice lines and to determine the barriers to adoption, facilitators and strategies to support the sustainability of GP advice lines within the Australian context.

This study aimed to: 1) identify the support and resources GPs need to manage urgent care patients in the community in coordination with virtual hospital services; 2) assess the need for GP advice lines by primary care services in Australia; and 3) identify the facilitators and barriers to adoption, and strategies to support the sustainability of GP advice lines.

Methods

Study design

This was a qualitative study involving semi-structured interviews. Reporting follows the Consolidated Criteria for Reporting Qualitative Research (COREQ; Appendix 1). [18] Ethics approval was received from Western Sydney Local Health District Human Research Ethics Committee (2022/ETH01690), in accordance with the Declaration of Helsinki and the National Statement on Ethical Conduct in Human Research. All participants provided informed consent. This study was funded by Sydney Health Partners and undertaken by Sydney Health Partners’ Virtual Care Clinical Academic Group (CAG). Sydney Health Partners is an accredited research translation centre that seeks to support the implementation of evidence-based practice into clinical practice and service delivery through partnership with academia (the University of Sydney) and local health services. Partners to the Virtual Care CAG include Northern Sydney Local Health District, Sydney Local Health District, Sydney Children’s Hospital Network and Western Sydney Local Health District. These health districts service metropolitan Sydney and the Network is a specialty paediatric service across the state.

Setting and participants

Eligible participants were stakeholders involved in urgent care coordination between primary care and hospital services (clinicians, consumer representatives, healthcare service management staff), including stakeholders directly involved in implementing GP advice lines in different Sydney regions and GP end-users. The four GP advice line services that were the focus of this study were implemented by Sydney Local Health District (SLHD), Northern Sydney Local Health District (NSLHD), Sydney Children’s Hospital Network (SCHN), and Western Sydney Local Health District (WSLHD):

  • SLHD established a GP advice line supported by GP Liaison Clinical Nurse Consultants, through the Royal Prince Alfred Virtual Hospital [19, 20] to provide assistance and advice to GPs in managing COVID-19 patients in the community.

  • NSLHD virtual hospital established a GP advice line to support GPs with COVID-19 symptom management and antiviral therapy.

  • SCHN established an advice line during the COVID-19 pandemic to support GPs in caring for high acuity children in the community.

  • WSLHD established the GP Specialist advice line as part of the Western Sydney Integrated Care Program, to support GPs in caring for chronic disease patients.

We used a purposive sampling technique, with initial participants identified by the Virtual Care CAG as key stakeholders. Additional participants were later recruited employing passive snowballing methodology i.e. relying on the natural and organic social networks of the Virtual CAG stakeholders and the initial participants. Potential participants were emailed a Participant Information and Consent Form and written consent was obtained prior to the interview.

Data collection techniques

Our semi-structured interview guide (see Appendix 2) was developed based on existing literature and discussion among co-authors and Steering Committee members (including GPs, other clinicians, consumers, healthcare service management staff). All semi-structured interviews were conducted by a researcher (DK) experienced in qualitative interviewing, between 21 February and 2 August 2023 (one via phone call; remaining via video conference). Recruitment ceased once thematic saturation was reached [21]. Interviews were digitally audio-recorded and transcribed verbatim.

Analysis

We used NVivo 1.7.1 (QSR International) to analyse transcripts. Thematic analysis was conducted line by line, using codes developed inductively, i.e. based on the data, using Braun and Clarke’s approach [22]. This approach included data familiarization, coding, generating initial themes, reviewing potential themes, defining and naming themes, and producing the report [22]. Specifically, ABA and LL repeatedly listened to the audio recording and familiarized themselves with the transcribed data by reading it multiple times before coding independently. After initial code generation, the researchers developed themes by merging codes with a shared meaning. Following this, the researchers reviewed the candidate themes to ensure coherent patterns were formed which contributed to the overall narrative and interpretation of the dataset. Finally, to ensure consistency and improve study rigour, the researchers discussed and reported the themes in relation to the dataset and the research aim. The two researchers met frequently throughout data collection and analysis to compare themes. Themes were discussed among the team of investigators until consensus was reached.

Results

A total of 16 participants were interviewed (median age 50 years; Interquartile range 38–59 years; 9 female), of whom 6 were GPs, 2 were consumer representatives, and others were health service managers (HSM) or healthcare professionals (HCP), some with overlap in functions (Table 1). Participants were from 3 different regions in Sydney: 5 from Northern Sydney, 4 from Central-Eastern and 5 from Western Sydney. Interviews had a mean duration of 39.6 min (range 12.2—66.6 min). Based on the aims of the study, three major themes emerged (Fig. 1): support and resources for GPs; motivation for GP advice lines; and factors influencing the uptake and sustainability of GP advice lines.

Table 1 Characteristics of the 16 interviewees
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Fig. 1
figure 1

Illustrative representation of themes and subthemes

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Support and resources for GPs to manage urgent care patients in the community

To support the management of urgent care patients in the community in coordination with virtual hospital services, three major needs were reported: keeping GPs informed about hospital care for their patients, clear referral pathways and knowledge and decision-making support.

a. Keeping GPs informed on hospital care for their patients.

Participants reported that keeping GPs in the loop regarding hospital care for their patients is critical to ensure continuity of care between tertiary and primary care. Participants stated that little or no information was being shared with GPs on the hospital care experienced by their patients, stating that: “the internal resident or registrar should be picking up the phone routinely for every admission and talking to the GP, involving the GP in care team meetings, so that they're actually part of the management plan and discharge planning. …we're unaware that they were admitted or discharged. We're just unaware that it even happened” – P11, GP.

b. Clear referral pathways.

Clear referral pathways was identified as a necessity as participants highlighted the complexity of the Australian healthcare system reporting that it is challenging to navigate for GPs particularly for those who gained their qualifications from other countries. For example, a participant said: “So, we need to provide them with really clear pathways in, they need to know who to ring, how to easily get through to someone, who's gonna be on the other end…it can be very difficult for them trying to navigate our system and to know… how to get through to the right department or the right specialist.” – P02, HSM.

It was also reported that there is a need for GPs to be able to refer patients to the hospital in a manner that bypasses the ED for direct access to care when the clinical requirements of the patient are clear: “I think the next step is having the GP able to directly refer patients into the hospital without going through ED for other types of care, and this might mean… treatment of wound care or fractures.” – P012, GP.

c. Knowledge and decision-making support.

Participants reported that it was key to provide knowledge and decision-making support to GPs to help determine whether the patient can be managed in their care or in hospital. For example, a participant said: “I suppose it's sort of critical decisions about whether someone's safe to be managed at home or not.” – P011, GP. Other participants clarified that knowledge support is not about providing generic clinical information but more about providing personalised actionable information based on the unique circumstances of individual patients: “[an] individual scenario needs to be tailored and we need advice on how to tailor it…it's not the clinical information we necessarily need, it's how to apply it.” – P08, GP. It was further noted that one way to provide timely, personalised, and actionable knowledge and decision-making support is through the use of GP advice lines.

Other general practice necessities reported by participants included: better awareness of existing support and having an adaptable funding model to allow GPs to be adequately remunerated for the management of urgent care patients in the community – see Table 2 for additional illustrative quotations.

Table 2 Illustrative quotes for theme “Needs/support and resources GPs require to manage urgent care patients in the community”
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Motivation for GP advice lines

The need for the advice lines was reported to have arisen from the shift to the community-based model of care for COVID-19 patients: “we had been asked to see … how general practice could start to take over care of COVID patients … well, what about if we had a GP advice line, that was for the GP's to ring up and speak to a GP in the virtual hospital”—P03, HSM.

a. Benefits of GP advice lines.

Participants stated that GP advice lines were beneficial because they helped to minimise knowledge gaps and increase GP confidence in their skills and expertise in managing urgent care patients during the period of uncertainty in the COVID-19 pandemic. For example, a participant reported that, “OK, I don't actually have to know every bit of minutiae, the people at the end of this line, doctor to doctor, will tell me what I need to do or know”—P07, GP, while another stated that, “sometimes you're just not quite sure and so you can just ring … so it's that confidence that you're making the right decision by the patient.”—P09, GP.

Another benefit of GP advice lines was that they facilitated an easier referral process, as GPs could speak to a specialist and directly get an appointment for the patient in a manner that bypasses the emergency department: “So, it allows them to get seen in a timely manner in the public system, but without having to go through the emergency department.”—P09, GP (see Table 3 for additional quotes).

Table 3 Illustrative quotes for theme “Motivation for GP advice lines”
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Factors influencing the uptake and sustainability of GP advice lines

A. Facilitators of GP advice lines.

Various facilitators to the use of the GP advice lines were identified by the participants, with the availability of a specialist response the most frequently reported. Participants stated specialist doctors with a level of seniority, training and experience, and preferably those with general practice expertise, are in the best position to be the receivers of the call; as this enabled the uptake and continuous use of the advice lines. A participant stated, “if you're calling the cardiology line, you'd want a cardiology AT who's working … in the rapid access clinic…. you get the best outcomes and the best communication when you're working like for like, so doctor to doctor.”—P05, HSM.

Also, GP advice line models that were designed to provide real-time support via synchronous communication between GPs and specialist doctors were preferred to models with asynchronous communication: “it was a great way for the GP's to be able to talk immediately, not e-mail someone and hope they get a response…. so it was this instantaneous decision making”—P07, GP.

Using various promotion strategies to create awareness of the purpose of, and how to use the advice line, was another facilitator. Participants further highlighted the primary health networks (PHNs) were a good avenue for disseminating information but insufficient to reach all GPs: “a lot of GP's have their own organisations … and some of those will go, ‘no, we don't have anything to do with the PHN’”—P13, GP.

Other reported facilitators to the GP advice lines included: co-designing the service with GPs and the availability of funding support (see Table 4 for additional quotes).

Table 4 Illustrative quotes for theme “Factors impacting the uptake and sustainability of GP advice lines”
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b. Barriers to the uptake of GP advice lines.

Participants noted some barriers to the uptake of GP advice lines. A key barrier was the limited hours of the service, which prevented GPs who work after hours and on weekends from using the service. For example, a participant stated that “but often I find I have to wait until 9:00 or 9:30 to call someone-…call an advice line. Most GP practises open at 8:00 or above.”- P08, GP while another said, “I definitely think having longer hours would have been good… people get sick on the weekends”—P03, HSM.

Another barrier that was raised was the lack of clarity on the role of the clinician on the receiver’s end of the call. Participants reported occasions where the GPs rang clinicians through the advice line but the receiver of the call was not fully aware of their role and unable to support GPs as needed to manage an urgent care patient in the community: “the only problems I've had are when I've rung the line and the person has no idea… what their role is.”—P09, GP.

Manual data collection was also noted as barrier to the use of the advice line, which makes it challenging to report on how the line is being used by GPs: “so with the GP advice line, we've done a lot of the data collection manually on spreadsheets… it's a bit clunky, doesn't make for easy reporting.”—P02, HSM (see Table 4 for additional quotations to support these themes).

c. Strategies to ensure the sustainability of GP advice lines.

To support the sustainability of the advice lines, participants emphasised the need to broaden the service from primarily focusing on COVID-19 to focus on other patient cohorts so that benefits can be felt by patients with a range of conditions in the broader community e.g. influenza. It was however noted that broadening the advice line service should be done cautiously: “we need to start small. We need to be specific to start with because if you open the door to every single condition, we'll just get overwhelmed easily. And [this] …is safer option as well …So, we're prepared to support and then gradually open the gate to support the wider community.”—P04, HSM.

Further digitising the advice line technologies, by providing additional electronic functionalities, was another strategy participants reported would be helpful in sustaining the advice lines. For example, a participant stated that, “if you look at the GP advice line in its current form, it's a phone service, … if there was… like a chat service that would allow,… [communication] via chat, …to discuss patient scenarios, secure sending of images…. real-time, sharing of images.”—P05, HSM.

Other participants indicated that the use of artificial intelligence (AI) driven clinical decision support tools, including the use of large language models such as Chat-GPT may have a role to play in complementing the advice lines. They noted that AI-driven tools could be integrated into practice software, and Health Pathways, such that a tiered level of support can be provided on low-risk concerns, while high risk issues would be handled through doctor-to-doctor conversations. For example, a participant stated that, “the advice line might be receiving calls that in the future could be handled through CHAT GPT AI type things…so the level of escalation may actually be for those that are a lot more serious, where you actually require a consultation with a fellow GP…”—P10, HSM.

Participants also reported that evaluation was imperative for the sustainability of the advice lines. Evaluating the advice lines was described to be critical to showcasing its benefits to enable ongoing support from funders: “so I thought, well if we can validate that this was a great utilisation of money, it connected GP’s to tertiary hospital, ensured that the patient had continuity of care as well, and if they were discharged from hospital.. by connecting them with their GP, then we would get ongoing funding.”—P01, HSM.

As part of an evaluation, participants stated that it was imperative to measure patient outcomes such as hospital presentation, and hospital admissions; clinician outcomes such as frequency of calls from a specific GP, reasons for the call, clinician experience and satisfaction; and health economic outcomes such as cost–benefit analysis: “I would love to look at some sort of evaluations that look at potential ED avoidance. Did this help avoid ED? You could then equate that to, you know, cost savings of ED admissions and bed stay and things like that as well” P05, HSM.

Consumer involvement was also highlighted as important in the ongoing use and expansion of the capabilities of GP advice lines. Participants indicated that the advice lines could evolve from a 2-way conversation to one that involves the GP, the specialist doctor and the patient. However, this was dependent on an alignment with the patient’s preference, and the patient’s level of health literacy. Nonetheless, it was noted that the current model of advice lines would benefit from trust between the GP and the patient, patient’s understanding and awareness of the usefulness of the advice lines and patient consent. A participant stated: “the only thing I’d want to be assured of was actually that advice line went through to a hospital and another clinical professional who was qualified to advise on whatever it was.” – P16, consumer. See Table 4 for more quotes.

Discussion

Our study assessed stakeholder perspectives on the support and resources GPs need for the management of urgent care patients in the community in coordination with hospital services, and identified the motivation for GP advice lines, as well as the barriers to adoption, facilitators and strategies to support the sustainability of GP advice lines. Our study revealed that better communication of hospital services with GPs is needed to facilitate continuity of care between primary and tertiary care services. Timely decision-support and advice, clear referral pathways, an adaptable funding model, and greater awareness of existing support were also identified as key aspects required to support GPs in managing urgent care patients. We also identified factors influencing the adoption of GP advice lines, including real-time availability of specialist advice (facilitator), limited hours of the advice line service (barrier) and need for robust evaluation of the advice line service (sustainability strategy).

Continuity and coordination of care are key elements of high-quality primary care [23,24,25] and our study revealed that improving these elements is seen as a key enabler for the management of urgent care patients in the community. Continuity of care can be defined as the degree to which patients experience the delivery of services by different providers in a coherent, logical, and timely fashion, based on three main types of continuity: informational, management, and relational [25]. Gaps in communication and information sharing between hospital and primary care clinicians were commonly highlighted as the main barrier to continuity and coordination of care. These deficits are well described in the literature, with direct communication between hospital doctors and GPs known to occur infrequently and impacting patient safety and health outcomes [15, 23, 24, 26,27,28,29]. Recently, an international cross-sectional study showed that a higher frequency of informal interactions between GPs and hospital doctors (for example, through the use of telephone calls to ask for advice) was associated with higher frequency of referral letters, discharge summaries, and feedback communications [30].

The ability for the GP to connect directly with the hospital specialist, rather than using a routing system, call-back procedure, or other asynchronous approaches, [31] has been reported as the most common format for telephone consultation services between doctors [32], and seems particularly relevant in the context of urgent care. Nevertheless, participants in our study also indicated the potential for other technologies to support GPs in managing urgent care patients. Other technologies such web-based platforms can facilitate sharing of medical record information [33,34,35,36], while also enabling doctors to communicate synchronously via audio or video call. Recently, the use of artificial intelligence-driven clinical decision support tools has become more common [37], with participants in our study also mentioning the potential of large language models and conversational artificial intelligence to support GPs regarding urgent care, with research needed on the feasibility, acceptability and safety of such AI-driven approaches [38, 39]. Importantly, trusting the source of the advice was highlighted as key in our study and others [40], which is even more important in the context of AI-driven support.

Limitations

Our recruitment strategy was based on a purposive sampling technique and a passive snowballing approach to increase the diversity of our sample, but we acknowledge that our sample is limited to Sydney, NSW and our findings may not be generalisable to the broader population. However, it is important to bear in mind that generalisability is not a goal of qualitative research. Rather, its objectives are to enable an in-depth exploration of the topic of interest, which we achieved in this study. Also, none of our interviews were conducted in-person and nuances generated from non-verbal cues could have been missed, particularly in the singular phone interview that was conducted. Nonetheless, online interviews provided easier logistical access to participants. Future research should focus on aspects that were outside of the scope of this study, such as evaluating process measures, as well as quality and safety of implemented GP advice lines.

Conclusion and recommendations

This qualitative study of stakeholder perspectives identified better coordination and continuity of care as key enablers for the management of urgent care patients in the community. GP advice lines were seen as supporting coordination and continuity of care by enabling GPs to remain the locus of patient care while leveraging hospital specialists’ expertise. With increasing technology sophistication, there remain opportunities to further digitise and optimise advice lines, whilst ensuring better integration within and across primary and tertiary care services. Based on the findings of this study, we provide recommendations for managing urgent care patients in the community.

  • 1. Tertiary care services should provide care information to GPs about their patients, clear referral pathways and timely decision-making support.

  • 2. GP advice lines require careful co-design and implementation, together with GPs, to ensure they are aligned with GP workflows. GP advice lines can be digitised to provide access to discharge information, and to support innovative models of care.

  • 3. PHNs and health service organisations can leverage the use of technologies to provide a tiered level of support, such as conversational AI-driven tools for low-risk issues, with high-risk issues being handled through doctor-to-doctor conversations.

  • 4. Researchers have a role to play in sustaining GP advice lines by conducting robust evaluation to determine its impact on patient, clinician, health service experience and outcomes.

  • 5. Health service organisations can provide better awareness of existing support (e.g. advice lines) to general practices, for example leveraging PHNs to communicate with affiliated GPs. In addition, local media campaigns can be implemented to inform the general public (and harder-to-reach GPs) about existing services aimed at strengthening the communication between hospitals and primary care.

  • 6. The government and policymakers should consider providing an adaptable funding model to support general practice services in caring for urgent care patients in the community.

Data availability

The datasets generated and analysed during the current study are not publicly available due to ethics restrictions but may be available from the corresponding author on reasonable request pending ethics approval.

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Acknowledgements

None.

Funding

This work was supported by a Sydney Health Partners Round 1 Clinical Academic Groups Funding Opportunity.

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Author notes

  1. Tim Shaw and Liliana Laranjo are co-senior authors.

Authors and Affiliations

  1. Faculty of Medicine and Health, The University of Sydney, Biomedical Informatics and Digital Health, Sydney, Australia

    Adeola Bamgboje-Ayodele, Nicki Newton & Melissa Baysari

  2. Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

    Meredith Makeham, Kavisha Shah, Fiona Robinson, Sarah Norris, Jagdev Singh & Tim Shaw

  3. Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

    Diane Kancijanic, Clara K. Chow & Liliana Laranjo

  4. Sydney Local Health District, Sydney, Australia

    Miranda Shaw & Owen Hutchings

  5. Northern Sydney Local Health District, Sydney, Australia

    Adam Johnston

  6. Sydney Children’s Hospitals Network, Sydney, Australia

    Jagdev Singh

  7. Department of Cardiology, Westmead Hospital, Sydney, Australia

    Clara K. Chow

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  1. Adeola Bamgboje-Ayodele
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  15. Liliana Laranjo
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Contributions

Conceptualisation: LL, TS, CKC, MM, MS, SN, MB; Data collection and analysis: LL, DK, AB; Interpretation of findings: AB, MM, DK, NN, KS, MS, AJ, FR, OH, SN, JS, MB, CKC, TS, LL; First draft: AB, LL; Revision of manuscript: AB, MM, DK, NN, KS, MS, AJ, FR, OH, SN, JS, MB, CKC, TS, LL.

Corresponding author

Correspondence to Liliana Laranjo.

Ethics declarations

Ethics approval and consent to participate

Ethics approval was received from Western Sydney Local Health District Human Research Ethics Committee (2022/ETH01690), in accordance with the Declaration of Helsinki and the National Statement on Ethical Conduct in Human Research. All participants provided informed consent.

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The authors declare no competing interests.

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Bamgboje-Ayodele, A., Makeham, M., Kancijanic, D. et al. How primary and tertiary care services collaborate in urgent care delivery: an evaluation of general practice advice lines. BMC Prim. Care 25, 406 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12875-024-02649-1

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Keywords

BMC Primary Care

ISSN: 2731-4553

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