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General practitioner consultation after a visit to the emergency department: an observational study

General practitioner consultation after a visit to the emergency department: an observational study Abstract Background Some studies have demonstrated an association between poor continuity of care, high likelihood of ‘inappropriate’ use of emergency departments (EDs) and avoidable hospitalization. However, we lack data concerning primary care use after an ED visit. Objective Identify the determinants of a visit to the general practitioner (GP) after an ED visit. Methods Design Observational study (single-centre cohort) Setting One emergency department in Paris, France. Subjects All adult patients who presented at the ED and were discharged. Main outcome measure We collected data by the use of a standardized questionnaire, patients’ medical records and a telephonic follow-up. Descriptive analyses were performed to compare individuals with and without a GP. Then, for those with a GP, multivariate logistic regression was used to identify the determinants of the GP consultation. Results We included 243 patients (mean age 45 years [±19]); 211 (87%) reported having a GP. Among those who reported having a GP, 52% had consulted their GP after the ED visit. Not having a GP was associated with young age, not having complementary health insurance coverage, and being single. GP consultation was associated with increasing age [adjusted odds ratios (aOR) = 1.03], poor self-reported health status (aOR = 2.25), medical complaints versus traumatic injuries (aOR = 2.24) and prescription for sick note (aOR = 5.74). Conclusion Not having a GP was associated with factors of social vulnerability such as not having complementary health insurance coverage. For patients with a GP, consultation in the month after an ED visit seems appropriate, because it was associated with poor health status and medical complaints. Primary care, continuity of care, health care access, emergency departments Introduction Primary health care is a major part of health systems, organization and policy (1–4). Previous publications reported better health outcomes and lower costs for health systems based on primary care than specialty care (5,6). In parallel, the impact of emergency medicine on primary and secondary prevention has been widely described by the public health review published by the WHO in 2008 (7,8). Having a general practitioner (GP) and good continuity of care is associated with decreased frequency of emergency department (ED) visits (9–13). Some authors have also demonstrated an association between poor continuity of care and high likelihood of ‘inappropriate’ use of ED care and avoidable hospitalization (6,14–16). ED utilization related to barriers in primary care access is an important indicator of the health care system performance. Recent studies have demonstrated the existence of significant social disparities in health (17–19) and healthcare access (20,21) all over the world. In addition, some studies had underlined the association between poor or no complementary health insurance coverage, difficulties in health care access and increased frequency of ED visits (22–24). Almost a quarter of ED use is due to a problem with primary care access (22,25–32). Community health centres could help reduce ED visit rates for uninsured patients (33). One strategy for reducing unnecessary ED utilization is to promote access to primary care, specifically for vulnerable people. Some studies have demonstrated that interventions aiming to enhance follow-up after an ED visit are associated with better healthcare continuity and reduced ED visits (34), more specifically for children with asthma (35–37) and older patients (14). Therefore, primary care use after an ED visit should be investigated because it reflects good continuity of care and could prevent further hospitalization and/or ED visits. The objective of this study was to identify the determinants of GP visits after an ED visit. We assume that some indicators of social vulnerability (such as poor complementary health insurance coverage) may be associated with reduced rate of GP consultation. METHODS This was a cohort study performed in one ED (Saint-Antoine Hospital in Paris, France which is a university hospital with about 60000 ED visit per year), during a 7-day period in June 2016 (night and day). The data were prospectively collected by use of a standardized questionnaire and from patients’ medical records. Patients, or their next of kin, were informed about the study and that their data might be used. They could refuse inclusion in the study. Patients We included patients who presented to the ED and were discharged after the ED visit. We excluded all patients younger than 18 years and those for whom data collection was not possible (dementia, inability to communicate), with impossible follow-up (no French phone number or homeless), who left the ED without being seen or who refused to participate. Questionnaire (detailed in Supplementary Table 1) A questionnaire of 14 questions was developed by the authors and was tested with a panel of 20 patients before the beginning of the study. The questionnaire was corrected and clarified according to patients’ feedback and comments. The questionnaire was distributed during the waiting time before the first medical contact and was completed with the help of an investigator if necessary. Some of the items were completed by the investigator based on the medical record. We included in the analysis only questionnaires for discharged patients. The questionnaire collected data on demographic characteristics, medical characteristics and the ED visit and care. The section on demographics included age, gender, marital status (used as a proxy of family support), education (high school graduate or not), employment status (employed/unemployed) and complementary health insurance coverage (none/private or universal health coverage [in France, CMU-c]). Below a determined income threshold, individuals can benefit from free governmental complementary health insurance, the CMU-c, to cover re-insurable co-payments not covered by public health insurance. The first section also asked about having a GP (yes/no) and the GP’s location (i.e. Paris district). The second section asked about medical conditions and health status. We used the Minimum European Health Module (MEHM) (38–41) to assess health status. Although the MEHM is a self-reported measure of health status, a number of studies suggested that MEHM is a good indicator of morbidity and mortality but also healthcare consumption (40,41). The third section asked about the current ED visit and care: day and time of ED visit (week day/night or weekend), chief complaint of consultation (medical complaint versus injury), prescription for blood tests or radiological exams, and prescription for sick note (yes/no). Primary outcome Our primary outcome was patients’ consulting with a GP in the month after the initial ED visit. After each included ED visit, patients were contacted by phone at 1 month and were interviewed using a standardized questionnaire. They were asked if they had consulted their GP at least once in the month after the ED visit and if they had brought the ED medical report to their GP. Patients were considered lost to follow-up after 6 unsuccessful contact attempts. Statistical analysis Continuous data, which were normally distributed, are reported with mean (±SD). Categorical variables are reported with number (%). We used chi-square test or Student t test, as appropriate, to compare characteristics of patients (1) with and without a GP and (2) who had consulted or not consulted a GP at least once in the month after an ED visit (for patients who reported having a GP). To analyse the determinants of a GP visit after an ED visit, a multivariate logistic regression model was built for participants who reported having a GP, estimating adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Variables statistically significant at P < 0.10 on univariate analysis were included in the model. Despite a P value > 0.10, we included complementary health insurance coverage in the model because of its association with health care use, widely described in the literature. All statistical analyses involved use of SAS software (SAS/STAT Package 2002–2003 by SAS Institute Inc., Cary, NC). RESULTS Participant characteristics Among the 693 patients who consulted in the ED during the study period, 243 were included (Figure 1). In total, 63 patients were lost to follow-up and 80 patients were not included because of overcrowding in the ED. Included and excluded patients did not differ in characteristics (Supplementary Table 1). The mean age of included patients was 45 years (±19), and 46% (N = 111) were men (Table 1). About half were single (N=124) and 151 (62%) were employed (Table 1). Overall, 204 (84%) patients reported having a private complementary health insurance or CMU-c, and self-reported health status was reported as poor to very poor for 38 (16%). The chief complaint for the ED visit was traumatic injury for 107 (44%). Most patients (87%, n = 211) reported having a GP, and 110 (52%) had consulted their GP at least once in the month after an ED visit and 56 (27%) brought their medical report to the GP. In all, 31% of GPs (N = 75) were located close to the ED (Figure 2). Table 1. Characteristics of patients who reported having a GP and not having a GP, who visited an emergency department in 2016. With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Table 1. Characteristics of patients who reported having a GP and not having a GP, who visited an emergency department in 2016. With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Figure 1. View largeDownload slide Flow of patients in the study conducted in 2016. Figure 1. View largeDownload slide Flow of patients in the study conducted in 2016. Figure 2. View largeDownload slide GP’s location of study’s participants in 2016. Note: In dark blue, districts with 10–15% of study’s GPs. In medium blue, districts with 2–5% of study’s GPs. In light blue, districts with less than 2% of study’s GPs. Figure 2. View largeDownload slide GP’s location of study’s participants in 2016. Note: In dark blue, districts with 10–15% of study’s GPs. In medium blue, districts with 2–5% of study’s GPs. In light blue, districts with less than 2% of study’s GPs. Characteristics of patients who reported having a GP Not having a GP was associated with young age, no complementary health insurance coverage and being single (Table 1). Characteristics of patients who reported consulting a GP at least once after the ED visit Consulting a GP at least once in the month after an ED visit was associated with older age, poor to very poor self-reported health status, no self-reported perception of functional limitation, medical complaints and prescription for sick note (Table 2). Table 2. Characteristics of patients who consulted and did not consulted their general practitioner at least once in the month after the emergency department visit in 2016 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Table 2. Characteristics of patients who consulted and did not consulted their general practitioner at least once in the month after the emergency department visit in 2016 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Logistic regression model On multivariate analysis (Table 3), GP consultation was associated with increased age (aOR = 1.03; 95% CI = 1.01–1.05), poor self-reported health status and prescription for work sick note (aOR = 2.19, 95% CI = 1.01–5.74 and aOR = 4.08, 95% CI = 1.92–8.66) as well as a medical complaint versus traumatic injury (aOR = 2.24, 95% CI = 1.18–4.27). Table 3. Logistic regression model of general practitioner consultation in 2016 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. aOR, adjusted odds ratio; 95% CI, 95% confidence interval. View Large Table 3. Logistic regression model of general practitioner consultation in 2016 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. aOR, adjusted odds ratio; 95% CI, 95% confidence interval. View Large DISCUSSION In this study, we aimed to identify the determinants of a visit to the GP after an ED visit. We found two key results. First, 13% of patients reported not having a GP, especially individuals who were young, had no complementary health insurance coverage and were single. Second, for patients who reported having a GP, primary care use in the month after the ED visit was explained in part by poor self-reported health status, older age, medical complaints and prescription for sick note. We found no association with other socioeconomic factors, particularly complementary health insurance coverage. Frequency of chronic conditions increases with age, and older people are more often considered multi-morbid patients (i.e. with at least two chronic conditions) (42,43). A 2007 publication of the French institute for research and information in health economics (IRDES) (44) showed reduced likelihood of older than younger people not having a GP, which is consistent with our results. We also found that individuals without a GP were often single and without complementary health insurance coverage, which might be a sign of social isolation and vulnerability. In total, 13% of patients reported no complementary health insurance coverage, which was higher than in the general population (about 6% in 2007 in France) (45). Not having complementary health insurance coverage is a known barrier to accessing specialized outpatient and dental care (46), but its effect on primary care and thus on continuity of care remains unclear (29,30,47,48). In fact, because of the small number of patients, we analysed patients with private complementary health insurance coverage and CMU-c together. Having complementary health insurance coverage does not reflect its quality (i.e. level of coverage), therefore how well patient is reimbursed for his care (29,49–51). Heterogeneity in the quality of different complementary health insurance coverage could be a second explanation for the absence of significant results on multivariate analysis. We also found an association between prescriptions for sick note in the ED and GP consultation. In France, prescription for an extension of sick note is possible only from the initial prescribing doctor or the GP (52). No data are available on prescription for sick note and its extension after an ED visit. Patients who receive a prescription for sick note in the ED may be those with more severe conditions and/or painful diagnosis (53–55). Poor self-reported health status and medical complaints were also associated with consulting a GP in this context: those with higher needs were more likely to consult a GP after an ED visit. Among all patients, 44% had attended the ED for an injury, which is higher than that reported in the literature on emergency care (57–,59). Our target population concerned only patients who were not admitted to the hospital and this could be an explanation for the over-representation of patients with traumatic injuries. In addition, traumatic injuries were less frequent among individuals who consulted their GP versus those who did not. This finding could lead to underestimating the GP consultation after an ED visit. What is important to stress here is that about one in eight patients self-reported not having a GP and that it was partly explained by some indicators of social vulnerability. Even if we can assume that it is a population younger and most often without comorbidities (and thus probably with lowest health care needs), good continuity of primary care is still important as it might be a target population for prevention and health education. And for this reason, it may be worthwhile to evaluate interventions to improve the continuity of care of this population. Our study has several strengths. To the best of our knowledge, this is one of the few studies to investigate the determinants of primary care use after an ED visit. However, 63 patients were lost to follow-up and 80 were not included because of overcrowding of the ED at the study time. But, included and excluded patients did not differ in socioeconomic data, which suggests minimal potential selection bias. Second, our study was based on self-reported data. However, in case of in case of misunderstanding, the design of the survey planned the assistance of the patient by an investigator in the ED to respond to the questionnaire to limit the potential understanding biases. Third, this was a single centre study performed in France, which might decrease the external validity. But several European health systems are close to the French model and could benefit from this new perspective. Fourth, the survey was conducted in June, which might decrease the representativeness of our study population. But, some results from a nationwide survey, conducted in all French EDs, have shown that June is a month with a high rate of visits (56) and we assume that it is representative of the usual activity of the emergency services. Finally, we did not determine if the ED physician had told the patient to consult the GP and whether the consultation was directly related to the ED attendance, which might affect the decision to consult or not. CONCLUSION In one 7-day period in one hospital ED, 13% of patients reported not having a GP and about 50% had consulted their GP at least once in the month after the ED visit. Young patients, those with no complementary health insurance coverage and those who were single more often reported not having a GP and might benefit from dedicated interventions aiming to enhance primary care coordination. GP consultation in the month after the ED visit appears appropriate because it was related to poor health status and medical complaints. Declaration Conflict of interest: none. Acknowledgments The authors thank Laura Smales (BioMedEditing) for editing. JR and DN designed the study. JR, DN, YY and PCT drafted the paper. All authors revised and reviewed the paper. References 1. World Health Organization . Primary health care, report of the international conference on primary health care [Internet] . 1978 . whqlibdoc.who.int/publications/9241800011.pdf (accessed on 27 October 2016). 2. World Health Organization . 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General practitioner consultation after a visit to the emergency department: an observational study

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Abstract Background Some studies have demonstrated an association between poor continuity of care, high likelihood of ‘inappropriate’ use of emergency departments (EDs) and avoidable hospitalization. However, we lack data concerning primary care use after an ED visit. Objective Identify the determinants of a visit to the general practitioner (GP) after an ED visit. Methods Design Observational study (single-centre cohort) Setting One emergency department in Paris, France. Subjects All adult patients who presented at the ED and were discharged. Main outcome measure We collected data by the use of a standardized questionnaire, patients’ medical records and a telephonic follow-up. Descriptive analyses were performed to compare individuals with and without a GP. Then, for those with a GP, multivariate logistic regression was used to identify the determinants of the GP consultation. Results We included 243 patients (mean age 45 years [±19]); 211 (87%) reported having a GP. Among those who reported having a GP, 52% had consulted their GP after the ED visit. Not having a GP was associated with young age, not having complementary health insurance coverage, and being single. GP consultation was associated with increasing age [adjusted odds ratios (aOR) = 1.03], poor self-reported health status (aOR = 2.25), medical complaints versus traumatic injuries (aOR = 2.24) and prescription for sick note (aOR = 5.74). Conclusion Not having a GP was associated with factors of social vulnerability such as not having complementary health insurance coverage. For patients with a GP, consultation in the month after an ED visit seems appropriate, because it was associated with poor health status and medical complaints. Primary care, continuity of care, health care access, emergency departments Introduction Primary health care is a major part of health systems, organization and policy (1–4). Previous publications reported better health outcomes and lower costs for health systems based on primary care than specialty care (5,6). In parallel, the impact of emergency medicine on primary and secondary prevention has been widely described by the public health review published by the WHO in 2008 (7,8). Having a general practitioner (GP) and good continuity of care is associated with decreased frequency of emergency department (ED) visits (9–13). Some authors have also demonstrated an association between poor continuity of care and high likelihood of ‘inappropriate’ use of ED care and avoidable hospitalization (6,14–16). ED utilization related to barriers in primary care access is an important indicator of the health care system performance. Recent studies have demonstrated the existence of significant social disparities in health (17–19) and healthcare access (20,21) all over the world. In addition, some studies had underlined the association between poor or no complementary health insurance coverage, difficulties in health care access and increased frequency of ED visits (22–24). Almost a quarter of ED use is due to a problem with primary care access (22,25–32). Community health centres could help reduce ED visit rates for uninsured patients (33). One strategy for reducing unnecessary ED utilization is to promote access to primary care, specifically for vulnerable people. Some studies have demonstrated that interventions aiming to enhance follow-up after an ED visit are associated with better healthcare continuity and reduced ED visits (34), more specifically for children with asthma (35–37) and older patients (14). Therefore, primary care use after an ED visit should be investigated because it reflects good continuity of care and could prevent further hospitalization and/or ED visits. The objective of this study was to identify the determinants of GP visits after an ED visit. We assume that some indicators of social vulnerability (such as poor complementary health insurance coverage) may be associated with reduced rate of GP consultation. METHODS This was a cohort study performed in one ED (Saint-Antoine Hospital in Paris, France which is a university hospital with about 60000 ED visit per year), during a 7-day period in June 2016 (night and day). The data were prospectively collected by use of a standardized questionnaire and from patients’ medical records. Patients, or their next of kin, were informed about the study and that their data might be used. They could refuse inclusion in the study. Patients We included patients who presented to the ED and were discharged after the ED visit. We excluded all patients younger than 18 years and those for whom data collection was not possible (dementia, inability to communicate), with impossible follow-up (no French phone number or homeless), who left the ED without being seen or who refused to participate. Questionnaire (detailed in Supplementary Table 1) A questionnaire of 14 questions was developed by the authors and was tested with a panel of 20 patients before the beginning of the study. The questionnaire was corrected and clarified according to patients’ feedback and comments. The questionnaire was distributed during the waiting time before the first medical contact and was completed with the help of an investigator if necessary. Some of the items were completed by the investigator based on the medical record. We included in the analysis only questionnaires for discharged patients. The questionnaire collected data on demographic characteristics, medical characteristics and the ED visit and care. The section on demographics included age, gender, marital status (used as a proxy of family support), education (high school graduate or not), employment status (employed/unemployed) and complementary health insurance coverage (none/private or universal health coverage [in France, CMU-c]). Below a determined income threshold, individuals can benefit from free governmental complementary health insurance, the CMU-c, to cover re-insurable co-payments not covered by public health insurance. The first section also asked about having a GP (yes/no) and the GP’s location (i.e. Paris district). The second section asked about medical conditions and health status. We used the Minimum European Health Module (MEHM) (38–41) to assess health status. Although the MEHM is a self-reported measure of health status, a number of studies suggested that MEHM is a good indicator of morbidity and mortality but also healthcare consumption (40,41). The third section asked about the current ED visit and care: day and time of ED visit (week day/night or weekend), chief complaint of consultation (medical complaint versus injury), prescription for blood tests or radiological exams, and prescription for sick note (yes/no). Primary outcome Our primary outcome was patients’ consulting with a GP in the month after the initial ED visit. After each included ED visit, patients were contacted by phone at 1 month and were interviewed using a standardized questionnaire. They were asked if they had consulted their GP at least once in the month after the ED visit and if they had brought the ED medical report to their GP. Patients were considered lost to follow-up after 6 unsuccessful contact attempts. Statistical analysis Continuous data, which were normally distributed, are reported with mean (±SD). Categorical variables are reported with number (%). We used chi-square test or Student t test, as appropriate, to compare characteristics of patients (1) with and without a GP and (2) who had consulted or not consulted a GP at least once in the month after an ED visit (for patients who reported having a GP). To analyse the determinants of a GP visit after an ED visit, a multivariate logistic regression model was built for participants who reported having a GP, estimating adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Variables statistically significant at P < 0.10 on univariate analysis were included in the model. Despite a P value > 0.10, we included complementary health insurance coverage in the model because of its association with health care use, widely described in the literature. All statistical analyses involved use of SAS software (SAS/STAT Package 2002–2003 by SAS Institute Inc., Cary, NC). RESULTS Participant characteristics Among the 693 patients who consulted in the ED during the study period, 243 were included (Figure 1). In total, 63 patients were lost to follow-up and 80 patients were not included because of overcrowding in the ED. Included and excluded patients did not differ in characteristics (Supplementary Table 1). The mean age of included patients was 45 years (±19), and 46% (N = 111) were men (Table 1). About half were single (N=124) and 151 (62%) were employed (Table 1). Overall, 204 (84%) patients reported having a private complementary health insurance or CMU-c, and self-reported health status was reported as poor to very poor for 38 (16%). The chief complaint for the ED visit was traumatic injury for 107 (44%). Most patients (87%, n = 211) reported having a GP, and 110 (52%) had consulted their GP at least once in the month after an ED visit and 56 (27%) brought their medical report to the GP. In all, 31% of GPs (N = 75) were located close to the ED (Figure 2). Table 1. Characteristics of patients who reported having a GP and not having a GP, who visited an emergency department in 2016. With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Table 1. Characteristics of patients who reported having a GP and not having a GP, who visited an emergency department in 2016. With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) With a GP Without a GP Test statistic P Total n = 211 (87%) n = 32 (13%) n = 243 Age in years, mean (± SD) 47 (± 20) 36 (± 13) 3.76 0.0004 45 (± 19) Gender N (%)  Female 119 (56) 13 (41) 2.79 0.10 132 (54)  Male 92 (44) 19 (59) 111 (46) Complementary health insurance coverage N (%)  None 22 (10) 9 (28) 9.28 0.01 31 (13)  Private or CMU-C 183 (87) 21 (66) 204 (84)  Missing data 6 (3) 2 (6) 8 (3) Employment status N (%)  Employed 129 (61) 22 (69) 0.68 0.41 151 (62)  Unemployed 82 (39) 10 (31) 92 (38) Level of education N (%)  Less or equal to bachelor 98 (47) 19 (59) 1.80 0.18 117 (48)  High school graduate 112 (53) 13 (41) 125 (52) Marital status N (%)  Single 101 (48) 23 (72) 8.21 0.02 124 (51)  Married 66 (31) 8 (25) 74 (30)  Divorced, widowed 44 (21) 1 (3) 45 (19) Minimum European Health Module Self-reported health status N (%)  Average to very good 170 (81) 31 (97) 5.19 0.07 201 (83)  Poor to very poor 37 (18) 1 (3) 38 (16) Having a chronic condition N (%)  Yes 104 (49) 14 (44) 7.14 0.07 118 (49)  No 105 (50) 17 (53) 122 (50) Self-reported perception of functional limitation N (%)  Moderate to severe limitation 82 (39) 10 (31) 0.08 0.58 92 (38)  No limitation 127 (60) 22 (69) 149 (61)  Missing data 2 (1) 0 2 (1) Day and time of ED visit N (%)  Week day 128 (61) 22 (69) 0.77 0.38 150 (62)  Night of week end 83 (39) 10 (31) 93 (38) Chief complaint of consultation N (%)  Traumatic injury 87 (41) 20 (62) 5.10 0.02 107 (44)  Medical complaint 124 (59) 12 (38) 136 (56) Prescription of exams N (%)  Blood test 53 (25) 6 (19) 0.61 0.43 59 (24)  X-ray 55 (26) 15 (47) 0.01 0.02 70 (29)  Tomodensitometry 13 (6) 2 (6) 0.29 1 15 (6)  MRI 3 (1) 0 0.65 1 3 (1)  Echography 5 (2) 0 0.49 1 5 (2) Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Figure 1. View largeDownload slide Flow of patients in the study conducted in 2016. Figure 1. View largeDownload slide Flow of patients in the study conducted in 2016. Figure 2. View largeDownload slide GP’s location of study’s participants in 2016. Note: In dark blue, districts with 10–15% of study’s GPs. In medium blue, districts with 2–5% of study’s GPs. In light blue, districts with less than 2% of study’s GPs. Figure 2. View largeDownload slide GP’s location of study’s participants in 2016. Note: In dark blue, districts with 10–15% of study’s GPs. In medium blue, districts with 2–5% of study’s GPs. In light blue, districts with less than 2% of study’s GPs. Characteristics of patients who reported having a GP Not having a GP was associated with young age, no complementary health insurance coverage and being single (Table 1). Characteristics of patients who reported consulting a GP at least once after the ED visit Consulting a GP at least once in the month after an ED visit was associated with older age, poor to very poor self-reported health status, no self-reported perception of functional limitation, medical complaints and prescription for sick note (Table 2). Table 2. Characteristics of patients who consulted and did not consulted their general practitioner at least once in the month after the emergency department visit in 2016 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Table 2. Characteristics of patients who consulted and did not consulted their general practitioner at least once in the month after the emergency department visit in 2016 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Consulted a GP Did not consult a GP Test statistic P n = 110 (52%) n = 101 (48%) Age in years, mean (± SD) 51 (± 21) 42 (± 18) −3.19 0.002 Gender N (%)  Female 64 (58) 55 (54) 0.30 0.59  Male 46 (42) 46 (45) Health insurance coverage N (%)  None 9 (8) 13 (13) 0.02 0.37  Private or CMU-C 99 (90) 84 (83)  Missing data 2 (2) 4 (4) Employment status N (%)  Employed 67 (61) 62 (61) 0.01 0.94  Unemployed 43 (39) 39 (38) Level of education N (%)  Less or equal to bachelor 48 (44) 50 (50) 0.85 0.36  High school graduate 62 (56) 50 (50) Marital status N (%)  Single 47 (43) 54 (53) 2.92 0.23  Married 36 (33) 30 (30)  Divorced, widowed 27 (24) 17 (17) Minimum European Health module Self-reported health status N (%)  Average to very good 83 (75) 87 (86) 11.54 0.003  Poor to very poor 27 (25) 10 (10)  Missing data 0 4 (4) Having a chronic condition N (%)  Yes 64 (58) 40 (40) 8.78 0.01  No 46 (42) 59 (58)  Missing data 0 2 (2) Self-reported perception of limitation N (%)  Moderate to severe limitation 51 (46) 31 (31) 7.14 0.03  No limitation 59 (54) 68 (67)  Missing data 0 2 (2) Day and time of ED visit N (%)  Week day 68 (62) 60 (59) 0.13 0.72  Night of week end 42 (38) 41 (41) Chief complaint of consultation N (%)  Traumatic injury 36 (33) 51 (50) 6.86 0.01  Medical complaint 74 (67) 50 (50) Prescription of sick note N (%)  Yes 40 (36) 21 (21) 6.21 0.01  No 70 (64) 80 (79) Prescription of exams N (%)  Blood test 36 (33) 17 (17) 7.07 0.008  X-ray 28 (25) 27 (27) 0.04 0.83  Tomodensitometry 11 (10) 2 (2) 0.01 0.02  MRI 1 (1) 2 (2) 0.36 0.61  Echography 4 (4) 1 (1) 0.18 0.37 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. CMU-c, correspond to universal health coverage. View Large Logistic regression model On multivariate analysis (Table 3), GP consultation was associated with increased age (aOR = 1.03; 95% CI = 1.01–1.05), poor self-reported health status and prescription for work sick note (aOR = 2.19, 95% CI = 1.01–5.74 and aOR = 4.08, 95% CI = 1.92–8.66) as well as a medical complaint versus traumatic injury (aOR = 2.24, 95% CI = 1.18–4.27). Table 3. Logistic regression model of general practitioner consultation in 2016 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. aOR, adjusted odds ratio; 95% CI, 95% confidence interval. View Large Table 3. Logistic regression model of general practitioner consultation in 2016 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Variables aOR Regression coefficient 95% CI n = 200 Age 1.03 0.03 1.01–1.05 Gender  Male Ref  Female 1.17 0.16 0.63–2.19 Complementary health insurance coverage  None Ref  Private or CMU-C 2.32 0.84 0.80–6.73 Self-reported health status  Average to very good Ref  Poor to very poor 2.19 0.78 1.01–5.74 Self-reported perception of functional limitation  Moderate to severe limitation Ref  No limitation 0.84 −0.18 0.39–1.78 Prescription of sick note  No Ref  Yes 4.08 1.41 1.92–8.66 Chief complaint of consultation  Traumatic injuries Ref  Medical complaint 2.24 0.81 1.18–4.27 Significant P (P value < 0.05) are in bold character and italic form is used to separate values of test statistic from numbers and frequency. aOR, adjusted odds ratio; 95% CI, 95% confidence interval. View Large DISCUSSION In this study, we aimed to identify the determinants of a visit to the GP after an ED visit. We found two key results. First, 13% of patients reported not having a GP, especially individuals who were young, had no complementary health insurance coverage and were single. Second, for patients who reported having a GP, primary care use in the month after the ED visit was explained in part by poor self-reported health status, older age, medical complaints and prescription for sick note. We found no association with other socioeconomic factors, particularly complementary health insurance coverage. Frequency of chronic conditions increases with age, and older people are more often considered multi-morbid patients (i.e. with at least two chronic conditions) (42,43). A 2007 publication of the French institute for research and information in health economics (IRDES) (44) showed reduced likelihood of older than younger people not having a GP, which is consistent with our results. We also found that individuals without a GP were often single and without complementary health insurance coverage, which might be a sign of social isolation and vulnerability. In total, 13% of patients reported no complementary health insurance coverage, which was higher than in the general population (about 6% in 2007 in France) (45). Not having complementary health insurance coverage is a known barrier to accessing specialized outpatient and dental care (46), but its effect on primary care and thus on continuity of care remains unclear (29,30,47,48). In fact, because of the small number of patients, we analysed patients with private complementary health insurance coverage and CMU-c together. Having complementary health insurance coverage does not reflect its quality (i.e. level of coverage), therefore how well patient is reimbursed for his care (29,49–51). Heterogeneity in the quality of different complementary health insurance coverage could be a second explanation for the absence of significant results on multivariate analysis. We also found an association between prescriptions for sick note in the ED and GP consultation. In France, prescription for an extension of sick note is possible only from the initial prescribing doctor or the GP (52). No data are available on prescription for sick note and its extension after an ED visit. Patients who receive a prescription for sick note in the ED may be those with more severe conditions and/or painful diagnosis (53–55). Poor self-reported health status and medical complaints were also associated with consulting a GP in this context: those with higher needs were more likely to consult a GP after an ED visit. Among all patients, 44% had attended the ED for an injury, which is higher than that reported in the literature on emergency care (57–,59). Our target population concerned only patients who were not admitted to the hospital and this could be an explanation for the over-representation of patients with traumatic injuries. In addition, traumatic injuries were less frequent among individuals who consulted their GP versus those who did not. This finding could lead to underestimating the GP consultation after an ED visit. What is important to stress here is that about one in eight patients self-reported not having a GP and that it was partly explained by some indicators of social vulnerability. Even if we can assume that it is a population younger and most often without comorbidities (and thus probably with lowest health care needs), good continuity of primary care is still important as it might be a target population for prevention and health education. And for this reason, it may be worthwhile to evaluate interventions to improve the continuity of care of this population. Our study has several strengths. To the best of our knowledge, this is one of the few studies to investigate the determinants of primary care use after an ED visit. However, 63 patients were lost to follow-up and 80 were not included because of overcrowding of the ED at the study time. But, included and excluded patients did not differ in socioeconomic data, which suggests minimal potential selection bias. Second, our study was based on self-reported data. However, in case of in case of misunderstanding, the design of the survey planned the assistance of the patient by an investigator in the ED to respond to the questionnaire to limit the potential understanding biases. Third, this was a single centre study performed in France, which might decrease the external validity. But several European health systems are close to the French model and could benefit from this new perspective. Fourth, the survey was conducted in June, which might decrease the representativeness of our study population. But, some results from a nationwide survey, conducted in all French EDs, have shown that June is a month with a high rate of visits (56) and we assume that it is representative of the usual activity of the emergency services. Finally, we did not determine if the ED physician had told the patient to consult the GP and whether the consultation was directly related to the ED attendance, which might affect the decision to consult or not. CONCLUSION In one 7-day period in one hospital ED, 13% of patients reported not having a GP and about 50% had consulted their GP at least once in the month after the ED visit. Young patients, those with no complementary health insurance coverage and those who were single more often reported not having a GP and might benefit from dedicated interventions aiming to enhance primary care coordination. GP consultation in the month after the ED visit appears appropriate because it was related to poor health status and medical complaints. Declaration Conflict of interest: none. Acknowledgments The authors thank Laura Smales (BioMedEditing) for editing. JR and DN designed the study. JR, DN, YY and PCT drafted the paper. All authors revised and reviewed the paper. References 1. World Health Organization . Primary health care, report of the international conference on primary health care [Internet] . 1978 . whqlibdoc.who.int/publications/9241800011.pdf (accessed on 27 October 2016). 2. World Health Organization . 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Family Practice – Oxford University Press

Published: Mar 20, 2019

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