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'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making.

ABSTRACT: BACKGROUND:Demand is labelled 'clinically unnecessary' when patients do not need the levels of clinical care or urgency provided by the service they contact. OBJECTIVE:To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary. DESIGN:Realist review. METHODS:Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context-Mechanism-Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies. RESULTS:Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment-seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual. CONCLUSIONS:Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

SUBMITTER: O'Cathain A

PROVIDER: S-EPMC6978874 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making.

O'Cathain Alicia A Connell Janice J Long Jaqui J Coster Joanne J

Health expectations : an international journal of public participation in health care and health policy 20191029 1

<h4>Background</h4>Demand is labelled 'clinically unnecessary' when patients do not need the levels of clinical care or urgency provided by the service they contact.<h4>Objective</h4>To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.<h4>Design</h4>Realist review.<h4>Methods</h4>Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to Janu ...[more]

PMID: 31663219

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Project description:BackgroundHealth care systems are increasingly moving towards more integrated approaches. Shared decision making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; particularly for older people with complex needs. The aim of this review was to provide a context relevant understanding of how interventions to facilitate SDM might work for older people with multiple health and care needs, and how they might be applied in integrated care models.MethodsIterative, stakeholder driven, realist synthesis following RAMESES publication standards. It involved: 1) scoping literature and stakeholder interviews (n = 13) to develop initial programme theory/ies, 2) systematic searches for evidence to test and develop the theories, and 3) validation of programme theory/ies with stakeholders (n = 11). We searched PubMed, The Cochrane Library, Scopus, Google, Google Scholar, and undertook lateral searches. All types of evidence were included.ResultsWe included 88 papers; 29 focused on older people or people with complex needs. We identified four context-mechanism-outcome configurations that together provide an account of what needs to be in place for SDM to work for older people with complex needs. This includes: understanding and assessing patient and carer values and capacity to access and use care, organising systems to support and prioritise SDM, supporting and preparing patients and family carers to engage in SDM and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that allow older people to feel that they are respected and understood, and that engender confidence to engage in SDM.ConclusionsTo embed SDM in practice requires a radical shift from a biomedical focus to a more person-centred ethos. Service providers will need support to change their professional behaviour and to better organise and deliver services. Face to face interactions, permission and space to discuss options, and continuity of patient-professional relationships are key in supporting older people with complex needs to engage in SDM. Future research needs to focus on inter-professional approaches to SDM and how families and carers are involved.

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'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making.

Publications

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making.

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