Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Abstract

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.

Impact of the SARS-CoV-2 pandemic and associated lockdown measures on attendances at emergency departments in English hospitals: A retrospective database study

“… 19 O'Cathain et al suggest that clinically unnecessary ED visits in children are sometimes caused by parents’ fear of the consequences of failing to bring their child to ED. 17 The countervailing risk of SARS-CoV-2 infection may have acted to offset this tendency, reducing the level of clinically unnecessary ED visits in children. We note however that all-age attendances where no clinical problem was detected, reduced and subsequently increased at a very similar rate to ED attendances as a whole.…”

“…The first considers that patient decisions to attend ED which are influenced by three factors (i) symptom-related drivers such as anxiety and pain (ii) patient-related drivers such as coping capacity and feeling responsible for another's health and (iii) service-related drivers such as prior experience of ED, and availability of GP services. 17 The second framework classifies the factors that influence reductions in healthcare activity over the lockdown period: (i) the impact of policy choices (ii) changes in patient behaviour (iii) changes in the levels and types of morbidity. 18 The first framework is generic and longstanding, the second adds the COVID-19-pandemic context.…”

Understanding young adults’ reasons for seeking ‘clinically unnecessary’ urgent and emergency care: A qualitative interview study

“…While interview participants across all groups were strongly influenced by concern over the seriousness of symptoms and a desire for reassurance, our survey found those in the 18‐24 age group were likely to feel less confident in deciding when to go to a doctor with a health problem, and to worry that pain indicated a serious problem. 24 Additionally, those aged 18‐44 were more likely to feel overwhelmed when they had an unexpected health problem. 24 These data echo Turnbull et al's findings that young adults more frequently identified themselves as anxious and prone to worrying about their health and linked this to their use of urgent and emergency services.…”

“… 24 Additionally, those aged 18‐44 were more likely to feel overwhelmed when they had an unexpected health problem. 24 These data echo Turnbull et al's findings that young adults more frequently identified themselves as anxious and prone to worrying about their health and linked this to their use of urgent and emergency services. 22 This anxiety and lack of confidence may be an age effect: young adults may be facing unfamiliar symptoms for the first time and be less confident in making independent decisions about their seriousness, and have less familiarity with services.…”

“…In 2018/19, we conducted a mixed‐methods study to understand clinically unnecessary demand for the ambulance service, EDs and urgent GP appointments. 24 We focused some of this research on three groups perceived to be more likely to be clinically unnecessary users: young adults, parents of young children and those living in areas of deprivation. The study included a realist review of qualitative literature, 25 through which we developed ten ‘programme theories’ (PTs) to explain help‐seeking decisions (Figure 1 ).…”