Impact of an integrated general practitioner(GP)- paediatrician model on GP hospital referrals and GP paediatric care: a stepped wedge trial

Introduction: Like many countries, Australia’s hospital system is under pressure with pre-school children comprising the largest proportion of all primary care-type emergency department presentations. General practitioners (GPs) must refer patients to specialists and waiting times to see specialists in paediatric hospital clinics are up to 12 months. We therefore aimed to see if a new model of care, Strengthening Care for Children (SC4C), could reduce GP referrals to hospitals. Who did we engage? We co-designed our intervention with GPs, GP practice staff, hospital paediatricians, primary health care networks, clinical colleges, and families. We first piloted the model in 2018 before conducting this definitive trial. What did we do? We conducted a stepped wedge cluster randomised controlled trial of 21 general practice clinics in Victoria and New South Wales, Australia. The co-designed 12-month intervention comprised weekly then fortnightly GP-paediatrician co-consultation sessions for 6 months each; monthly paediatrician-led education and case discussions; and phone and email paediatrician support to GPs, focusing on topics selected by GPs. We collected data on GP referral destinations (primary outcome), GP experience and confidence in providing paediatric care, and calculated cost implications to the healthcare system. Results: Participating GPs (N=130) conducted 50,101 paediatric consultations during the Control period (May 2021 to end March 2022) and 96,804 during the Intervention period (July 2021 to end March 2023). During the Intervention period, 1984 co-consultations, 530 case discussions and 154 emails/phone calls occurred. There was a reduction in GP referrals to hospitals (Control period: 990 referred (2.30%) vs Intervention period:1398 referred (1.96%); risk difference (Intervention - Control) -0.34% (95% CI -0.69, 0.00), p= 0.053). This reduction strengthened when analysing high referring GPs (i.e. those referring 5% or more of children at baseline) - (Control period 3408 (7.31%) vs Intervention period 10,030 (3.03%), risk difference (Intervention - Control), -4.28%, (95% CI -6.59, -1.97), p <0.001). At an estimated cost of AUS$298 per patient referred and based on 96,804 children seen during the intervention period, a reduction in referrals of -0.34% represents a cost saving to the health care system of $98,082. For the 10,030 patients of high referring GPs the potential cost savings from referrals is $127,926. GPs also reported improved knowledge and skills in how to manage child health problems, how paediatric services are organised, and how to access them (all p <0.02). Learnings: GPs welcome the opportunity to strengthen their care with specialist colleagues, but it takes time to build trust and change practice. Initial on-site activities appeared to strengthen this trust, allowing for the model to continue during the COVID-19 pandemic via telehealth. Fee-for-service funding models can make it financially challenging for GPs to participate in longer (i.e., 30 minute) co-consultations. Next steps: We aim to cost and scale this model nationally, especially in areas of Australia where access to paediatricians is limited. Thus, we are trialling a telehealth version of this model in a stepped wedge trial in rural Australia. We are advocating for healthcare billing items to allow synchronous consultations with GPs and paediatricians.