Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study
Background: There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically u...
| Main Authors: | , , , , , , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
National Institute for Health Research
2020-03-01
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| Series: | Health Services and Delivery Research |
| Subjects: | |
| Online Access: | https://doi.org/10.3310/hsdr08150 |
| _version_ | 1818569244922609664 |
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| author | Alicia O’Cathain Emma Knowles Jaqui Long Janice Connell Lindsey Bishop-Edwards Rebecca Simpson Joanne Coster Linda Abouzeid Shan Bennett Elizabeth Croot Jon M Dickson Steve Goodacre Enid Hirst Richard Jacques Miranda Phillips Joanne Turnbull Janette Turner |
| author_facet | Alicia O’Cathain Emma Knowles Jaqui Long Janice Connell Lindsey Bishop-Edwards Rebecca Simpson Joanne Coster Linda Abouzeid Shan Bennett Elizabeth Croot Jon M Dickson Steve Goodacre Enid Hirst Richard Jacques Miranda Phillips Joanne Turnbull Janette Turner |
| author_sort | Alicia O’Cathain |
| collection | DOAJ |
| description | Background: There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use. Objectives: To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives. Design: This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking. Results: From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice. Limitations: Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service. Conclusions: Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered. Future work: There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions. Study registration: This study is registered as PROSPERO CRD42017056273. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information. |
| first_indexed | 2024-12-14T06:45:36Z |
| format | Article |
| id | doaj.art-ac3b7f41a6434038a2dee3919ae221bc |
| institution | Directory Open Access Journal |
| issn | 2050-4349 2050-4357 |
| language | English |
| last_indexed | 2024-12-14T06:45:36Z |
| publishDate | 2020-03-01 |
| publisher | National Institute for Health Research |
| record_format | Article |
| series | Health Services and Delivery Research |
| spelling | doaj.art-ac3b7f41a6434038a2dee3919ae221bc2022-12-21T23:13:05ZengNational Institute for Health ResearchHealth Services and Delivery Research2050-43492050-43572020-03-0181510.3310/hsdr0815015/136/12Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods studyAlicia O’Cathain0Emma Knowles1Jaqui Long2Janice Connell3Lindsey Bishop-Edwards4Rebecca Simpson5Joanne Coster6Linda Abouzeid7Shan Bennett8Elizabeth Croot9Jon M Dickson10Steve Goodacre11Enid Hirst12Richard Jacques13Miranda Phillips14Joanne Turnbull15Janette Turner16School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSheffield Emergency Care Forum, Sheffield, UKSheffield Emergency Care Forum, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKAcademic Unit of Primary Medical Care, University of Sheffield, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKSheffield Emergency Care Forum, Sheffield, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKNational Centre for Social Research, London, UKHealth Sciences, University of Southampton, Southampton, UKSchool of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UKBackground: There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use. Objectives: To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives. Design: This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking. Results: From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice. Limitations: Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service. Conclusions: Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered. Future work: There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions. Study registration: This study is registered as PROSPERO CRD42017056273. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.https://doi.org/10.3310/hsdr08150heath care seeking behaviourhealth care utilisationpatientsemergency medicineurgent carequalitative researchhealth surveysystematic reviewgeneral practiceemergency departmentsambulancesparentsyoung adultsocial deprivation |
| spellingShingle | Alicia O’Cathain Emma Knowles Jaqui Long Janice Connell Lindsey Bishop-Edwards Rebecca Simpson Joanne Coster Linda Abouzeid Shan Bennett Elizabeth Croot Jon M Dickson Steve Goodacre Enid Hirst Richard Jacques Miranda Phillips Joanne Turnbull Janette Turner Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study Health Services and Delivery Research heath care seeking behaviour health care utilisation patients emergency medicine urgent care qualitative research health survey systematic review general practice emergency departments ambulances parents young adult social deprivation |
| title | Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study |
| title_full | Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study |
| title_fullStr | Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study |
| title_full_unstemmed | Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study |
| title_short | Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study |
| title_sort | drivers of clinically unnecessary use of emergency and urgent care the deuce mixed methods study |
| topic | heath care seeking behaviour health care utilisation patients emergency medicine urgent care qualitative research health survey systematic review general practice emergency departments ambulances parents young adult social deprivation |
| url | https://doi.org/10.3310/hsdr08150 |
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