24 February 2020

Embedding paeds with GPs could pay dividends

General Practice Paediatrics

Embedding paediatricians in general practices could reduce emergency department visits and low value care, a trial in five GP clinics in Victoria suggests.

This has prompted calls for changes to Medicare item numbers to allow co-consults between GPs and specialists to better deal with the burden of chronic illness and support its management in primary care.

Despite a growing paediatric population, GPs are seeing fewer children and in shorter consultations.

“At the same time, we have seen big increases in presentation of children to emergency departments,” says Professor Harriet Hiscock, lead author of the study. “In fact, the biggest age group that comes to the ED is zero- to four-year-olds.”

Referrals to outpatient clinics have also been increasing, the paediatrician and Murdoch Children’s Research Institute researcher say, with some outpatient clinics now having waiting times of more than  12 months.

Many of these emergency department visits and referrals could be dealt with in primary care, but GPs often don’t feel like they have had the training and support to treat such conditions – particularly chronic illnesses, mental health and developmental-behavioural issues, Professor Hiscock says.

Her team decided to adapt an English model of care where paediatricians were integrated into general practice, to test its efficacy and cost-effectiveness.

The pilot study involved about 900 families visiting five general practices in north west Melbourne. Salaried paediatricians from the Royal Children’s Hospital were embedded in the general practices for 12 months, initially visiting in person weekly, and then fortnightly as the program progressed.

GPs and paediatricians also had monthly case discussions and were available for clinical support via phone and email.

Dr Umair Masood, a GP involved in the pilot program, called it “a raging success”.

The intervention led to a 20% reduction in the unnecessary prescribing of acid suppression medications to treat reflux or unsettled behaviour in infants, from 29% before the intervention to 9% after the intervention. Unnecessary antibiotic and steroid prescribing for bronchitis also dropped by 9%.

This model of care also improved families’ confidence in GP care, up from 78% to 94%.

There was a trend towards fewer referrals to private paediatricians (from 34% to 20%) and emergency department visits (from 19% to 12%), although it wasn’t statistically significant.

GPs also reported more confidence in treating common childhood conditions.

“One of the things that I personally found interesting and helpful was the management and diagnosis of ADHD,” Dr Masood says.

The paediatricians taught Dr Masood and his colleagues how to use and interpret diagnostic questionnaires for developmental and behavioural conditions.

“Previously we were just referring anyone with query of ADHD,” he says. But now they do a thorough work up of the child, including hearing and eyesight checks and asking parents and teachers to fill out relevant questionnaires.

The benefits of this approach were twofold. Firstly, it enabled GPs to refer directly to a more appropriate specialist, such as a psychologist, if necessary. Secondly, it streamlined referrals and diagnoses with paediatricians.

Instead of two or three appointments with a paediatrician, they can get a diagnosis and start treatment immediately,  Professor Hiscock says.

The saved travel costs and time off work to visit hospitals and appointments equated to $150,000 less that families had to spend over the 12 months.

When the savings to families and state and federal government were factored in, the additional costs of the study and MBS billing equated to an additional $172 for each of the 624 co-consults undertaken.

But without study costs, implementing this approach would be a cost-saving measure for the healthcare system, Professor Hiscock says.

“Medicare was designed 50 years ago for acute medical problems. It’s not designed to deal with modern medicine, which is chronic illness, developmental, behavioural and mental health problems,” she says.

New Medicare item numbers that allow for co-consulting, or funding by PHNs, are key to driving this new approach, she says.

Outpatient clinic referrals remained the same during the study, but increased after the paediatrician left (31% to 47%).

The team are currently undertaking a larger study of 22 general practices across NSW and Victoria.

Australian Health Review

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