# Strengthening Care for Children (SC4C), an Integrated Paediatrician–General Practitioner Model for Reducing Hospital Referral Rates: A Stepped‐Wedge Cluster Randomised Controlled Trial

## TL;DR

A new model where pediatricians support general practitioners reduced hospital referrals for children, especially among doctors who referred many patients before.

## Contribution

An integrated GP-paediatrician model was tested to sustainably reduce hospital referrals for children in high-referral practices.

## Key findings

- Hospital referrals decreased from 7.3% to 3.0% for GPs with high baseline referral rates.
- GP confidence in child healthcare increased during the intervention period.
- Family preference for GP-led care remained high throughout the study.

## Abstract

To assess the effectiveness of Strengthening Care for Children (SC4C) for reducing the number of referrals by general practitioners of patients under 18 years of age to hospital services.

Stepped‐wedge cluster randomised trial; data collected for up to 16 months after the intervention.

General practices in North Western Melbourne and Central and Eastern Sydney primary health networks, 1 May 2021–30 September 2023.

General practitioners who worked at least two clinical sessions each week, saw patients under 18 years of age, and for whom at least 1 month of referrals data during the control period were available; families of people under 18 years attending these practices.

Weekly (6 months) then fortnightly (6 months) general practitioner–paediatrician co‐consultations; monthly paediatrician‐led case discussions; weekday phone and email support by paediatricians.

Proportion of general practitioner visits in which patients were referred to publicly funded hospital outpatient clinics or emergency departments (patient level), overall and by baseline referral rate. Secondary outcomes: Referrals after completion of the intervention; general practitioner confidence regarding child health care; low value care for frequent childhood conditions; family preference for general practitioner or paediatrician care.

One hundred and thirty participating general practitioners from 22 general practices conducted 50,101 consultations during the control period; 125 general practitioners from 21 general practices received the intervention and undertook 96,804 consultations. Patients were referred to hospitals in 2.3% of control period consultations and 1.9% of intervention period consultations (risk difference, −0.34 [95% confidence interval {CI}, −0.69 to 0.004] percentage points). Among general practitioners with high referral rates at baseline (5% or higher), patients were referred to hospital outpatient or emergency department in 7.3% of control period consultations and in 3.0% of intervention period consultations (risk difference, −4.28 [95% CI, −6.59 to −1.97] percentage points); the referral rate was also lower after the intervention period (sustainability vs. control periods: 2.9% vs. 5.8%; risk difference, −2.92 [95% CI, −5.36 to −0.48] percentage points). The proportions of general practitioners confident about their knowledge and skills regarding child health care were larger during the intervention than the control period. Quality of care and family preference for general practitioner‐led care for their children remained high across the study. No adverse events were recorded.

Strengthening primary care for children reduces the frequency of hospital referrals of children by general practitioners with high referral rates, increases rates of general practitioner confidence about caring for children and maintains family preference for general practitioner‐led care.

Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620001299998 (prospective)

The demand for hospital outpatient and emergency services for children is rising in high income countries. Integrated care models in which paediatricians support care by general practitioners could reduce the number of hospital referrals.

An integrated general practitioner–paediatrician model did not reduce hospital referrals overall, but sustainably reduced referrals of children by general practitioners who had previously referred 5% or more of patients under 18 years of age.

To relieve pressure on hospitals and improve equitable access to specialist care, this care model could be expanded to include general practices in areas with high numbers of children and general practitioners with high referral rates.