GP assessment of unmet need in a complex multimorbid population using a data-driven and clinical triage system: a prospective cohort study

Parry, Emma; Ahmed, Kamran; Evans, Simon; Guest, Elizabeth; Klaire, Vijay; Koodaruth, Abdool; Labutale, Prasadika; Matthews, Dawn; Lampitt, Jonathan; Pickavance, Gillian; Sidhu, Mona; Warren, Kate; Singh, Baldev

Abstract

Patients with unmet healthcare needs are more likely to access unscheduled care. Identifying these patients through data driven and clinical risk stratification for active case management in primary care can help address patient need and reduce demand on acute services. Determine how a proactive digital healthcare system can be used to undertake comprehensive needs analysis of patients at risk of unplanned admission and mortality. Prospective cohort study of 6 general practices in a deprived UK city. To identify those with unmet needs our population underwent digitally driven risk stratification into Escalated and Non-escalated groups using seven risk factors. The Escalated group underwent further stratification using GP clinical assessment into Concern and No Concern groupings. The Concern group underwent Unmet Needs Analysis (UNA). From 24,746, 515 (2.1%) were triaged into the Concern group and 164 (0.6%) underwent UNA. These patients were more likely to be older (t=4.69, <0.001), female (X =4.46, <0.05), have a PARR score ≥80 (X =4.31, <0.05), be a nursing home resident (X =6.75, <0.01) or on an end-of-life register (X =14.55, <0.001). Following UNA 143(87.2%) patients had further review planned or were referred for further input. The majority of patients had 4 domains of need. In those who GPs would not be surprised if they died within the next few months n=69 (42.1%) were not on an EOL register. This study showed how an integrated, patient centred, digital care system working with GPs can highlight and implement resources to address the escalating care needs of complex individuals. [Abstract copyright: Copyright © 2023, The Authors.]

Citation

Parry, E., Ahmed, K., Evans, S., Guest, E., Klaire, V., Koodaruth, A., Labutale, P., Matthews, D., Lampitt, J., Pickavance, G., Sidhu, M., Warren, K., & Singh, B. (2023). GP assessment of unmet need in a complex multimorbid population using a data-driven and clinical triage system: a prospective cohort study. British Journal of General Practice Open (BJGP Open), 7(4), https://doi.org/10.3399/BJGPO.2023.0078

• Journal Article Type: Article
• Acceptance Date: Jun 23, 2023
• Online Publication Date: Jun 29, 2023
• Publication Date: Sep 19, 2023
• Deposit Date: Jul 21, 2023
• Journal: BJGP Open
• Print ISSN: 2398-3795
• Electronic ISSN: 2398-3795
• Publisher: Royal College of General Practitioners
• Peer Reviewed: Peer Reviewed
• Volume: 7
• Issue: 4
• DOI: https://doi.org/10.3399/BJGPO.2023.0078
• Keywords: MDT, end of life, urgent care, multimorbidity, Clinical risk, integrated care networks, needs analysis, risk stratification
• Public URL: https://keele-repository.worktribe.com/output/516913