Exploring the relationship between the quality of primary care and demand for emergency care

Student thesis: Phd


Avoidable emergency care use is of growing interest to policymakers. It is often suggested to be symptomatic of sub-optimal primary care. However, understanding of what constitutes avoidable use and how this relates to primary care is limited and inconsistent. The aim of this thesis is to evaluate the concept of avoidable emergency department (ED) use and explore whether different types of potentially avoidable ED attendances are related to primary care quality. I reviewed the literature on the concept and identification of avoidable ED attendances and highlighted inconsistencies in the terminology, the underlying definition, and the method used to identify them. I presented a more nuanced typology defining avoidable attendances based on the level of care required upon attendance: (1) clinically divertible attendances - patients who would have been more appropriately treated elsewhere; (2) clinically unnecessary attendances - patients who did not require any clinical care; and (3) clinically preventable attendances - patients who required ED care, but whose attendance could have been prevented with earlier intervention or better condition management. I applied three previously used definitions of unnecessary and divertible attendances to individual level data on all ED attendances in England. I estimated associations between GP practice counts of these attendances and indicators of primary care quality, and then estimated the number of attendances associated with below-average levels of primary care quality. Volumes of unnecessary attendances were negatively associated with patient-reported telephone access and ability to make an appointment. However, only 4% of such attendances were associated with levels of primary care quality below the national average. I identified six hospital Trusts in England whose ED diagnosis data facilitated the identification of preventable attendances for the first time, classified based on the set of ambulatory care sensitive conditions (ACSCs) used in national performance indicators. I examined the extent and composition of preventable emergency care that is missed when only admissions for ACSCs are counted in performance measures. I estimated 11% of ED attendances were for ACSCs, with most being for acute rather than chronic conditions (59% versus 38%). The majority (55%) of ACSC attendances did not result in hospital admission. The likelihood of admission varied substantially between conditions and by patient characteristics. Finally, I revisited the association between avoidable attendances and primary care quality, using data from the same six Trusts and now including preventable attendances. In total 22% of attendances were classified as avoidable. Attendances classified as avoidable were not significantly associated with any measures of primary care quality, whilst attendances classified as unavoidable were negatively associated with clinical quality and appointment availability. The work presented in this thesis shows that it is important to define clear concepts and use standardised methods when identifying types of avoidable ED attendances. This would enable replicability and comparability, and rigorous evaluations of interventions aiming to reduce avoidable ED use. Improvements to the quality of primary care services would result in only modest reductions in avoidable attendances. Avoidable attendances should be used with caution as a performance measure for primary care services. Initiatives to reduce ED use might be better directed at population level factors.
Date of Award31 Dec 2021
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorKatherine Checkland (Supervisor), Matthew Sutton (Supervisor) & Rachel Meacock (Supervisor)


  • primary care
  • emergency department
  • avoidable use

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