Reasons for attending an urban urgent care centre with minor illness: a questionnaire study

Health Status of Nonemergency Patients in the Emergency Department Using the EQ-5D

Background

Emergency department (ED) overcrowding is influenced by several factors including the hospital's capacity, staff, patient discharges, and community resources. The number of annual ED visits has increased, with patients' medical needs exceeding emergency capacity, resulting in a widespread concern about emergency room overcrowding. Nonemergency patients tend to use large amounts of emergency medical resources, which is one reason for ED overcrowding. Most patients consider their medical cases urgent, whereas medical professionals consider many cases to be nonemergency. Only a few studies have examined self-rated health among nonemergency patients.

Methods

This cross-sectional study was conducted in the ED of a tertiary hospital in China using the European Quality of Life Five-Dimensional Questionnaire to investigate the health status of nonemergency patients.

Results

Among the 545 respondents, 246 (45.14%) self-assessed their health as excellent, 186 (34.13%) as very good, 70 (12.84%) as good, 32 (5.87%) as average, and 11 (2.02%) as poor. Problems related to pain/discomfort were reported by 317 (58.17%) participants, 214 (39.27%) responded that they had problems related to daily activities, 212 (38.90%) responded that they felt anxious or depressed, 211 (38.35%) responded that they had problems related to self-care, and some or extreme problems related to mobility were stated by 193 people (35.41%).

Conclusions

Nonemergency patients generally reported good health. Pain/discomfort was the most significant factor affecting the health of nonemergency patients, followed by limitation of daily activities. The duration of illness onset and self-rated health status were common factors influencing the health status of nonemergency patients. This trial is registered with ChiCTR1900023578.

An integrative review of adult patient-reported reasons for non-urgent use of the emergency department

OBJECTIVE

To conduct an integrative review of the scientific literature to explore adult patient-reported reasons for using the emergency department (ED) non-urgently.

METHOD

A literature search of CINAHL, Cochrane, Embase, PsycINFO, and MEDLINE was conducted with filters for humans, published January 1, 1990-September 1, 2021, and English language. Methodological quality was assessed using Critical Appraisal Skills Programme Qualitative Checklist for qualitative and National Institutes Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies for quantitative studies. Data was abstracted on study and sample characteristics, and themes/reasons for ED use. Cited reasons were coded using thematic analysis.

RESULTS

Ninety-three studies met inclusion criteria. Seven themes were found: need to be risk averse with respect to the health issue; knowledge and awareness of alternative sources of care; dissatisfaction with primary care provider; satisfaction with ED; ED accessibility and convenience resulting in low access burden; referred to the ED by others; and relationships between patients and health care providers.

DISCUSSION

This integrative review examined patient-reported reasons for attending the ED on a non-urgent basis. The results suggest that ED patients are heterogenous and many factors influence their decision-making. Considering the complexity with which patients live, treating them as a single entity may be problematic. Limiting excessive non-urgent visits likely requires a multi-pronged approach.

CONCLUSION

For many ED patients, they have a very clear problem which needed to be addressed. Future studies should explore psychosocial factors driving decision-making (e.g., health literacy, health-related personal beliefs, stress and coping ability).

Strength in the gap: A rapid review of principles and practices for urgent care centres

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining "after-hours care," "ambulatory care," "emergency medicine," "urgent care," "minor emergency," "walk-in," and "Canada" over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

The impact of COVID-19 on an Irish Emergency Department (ED): a cross-sectional study exploring the factors influencing ED utilisation prior to and during the pandemic from the patient perspective

BACKGROUND

The collateral damage of SARS-CoV-2 is a serious concern in the Emergency Medicine (EM) community, specifically in relation to delayed care increasing morbidity and mortality in attendances unrelated to COVID-19. The objectives of this study are to describe the profile of patients attending an Irish ED prior to, and during the pandemic, and to investigate the factors influencing ED utilisation in this cohort.

METHODS

This was a cross-sectional study with recruitment at three time-points prior to the onset of COVID-19 in December 2019 (n = 47) and February 2020 (n = 57) and post-Lockdown 1 in July 2020 (n = 70). At each time-point all adults presenting over a 24 h period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Data analysis was performed in SPSS and included descriptive and inferential statistics.

RESULTS

The demographic and clinical profile of patients across time-points was comparable in terms of age (p = 0.904), gender (p = 0.584) and presenting complaint (p = 0.556). Median length of stay in the ED decreased from 7.25 h (IQR 4.18-11.22) in February to 3.86 h (IQR 0.41-9.14) in July (p ≤ 0.005) and differences were observed in disposition (p ≤ 0.001). COVID-19 influenced decision to attend the ED for 31% of patients with 9% delaying presentation. Post-lockdown, patients were less likely to attend the ED for reassurance (p ≤ 0.005), for a second opinion (p ≤ 0.005) or to see a specialist (p ≤ 0.05).

CONCLUSIONS

Demographic and clinical presentations of ED patients prior to the first COVID-19 lockdown and during the reopening phase were comparable, however, COVID-19 significantly impacted health-seeking behaviour and operational metrics in the ED at this phase of the pandemic. These findings provide useful information for hospitals with regard to pandemic preparedness and also have wider implications for planning of future health service delivery.

The “better data, better planning” census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland

Background

Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of “Corridor Medicine” and “Trolley Crises” have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland.

Methods

This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED.

Results

Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the “best place” for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan.

Conclusions

This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07841-6.

A mixed methods investigation of behavioural drivers influencing Emergency Department attendance in Victoria during the 2020 COVID-19 pandemic

Objective

To identify behavioural drivers and barriers that may have contributed to changes in ED attendance during the first 10 months of the coronavirus disease 2019 (COVID‐19) pandemic in Victoria.

Methods

We conducted a mixed methods analysis of patients who attended one of eight participating EDs between 1 November 2019 and 31 December 2020. A random sample of patients were chosen after their visit and invited to participate in an online survey assessing behavioural drivers and barriers to attendance. The study timespan was divided into four periods based on local and world events to assess changes in attitudes and behaviours over this period.

Results

A total of 5600 patients were invited to complete the survey and 606 (11%) submitted sufficient information for analysis. There were significant differences in participants' attitudes towards healthcare and EDs, levels of concern about contracting and spreading COVID‐19 and the influence of mask wearing. Patients expressed more concern about the safety of an ED during the largest outbreak of COVID‐19 infections than they did pre‐COVID, but this difference was not sustained once community infection numbers dropped. General concerns about hospital attendance were higher after COVID than they were pre‐COVID. A total of 27% of patients specifically stated that they had delayed their ED attendance.

Conclusion

Patients expressed increased concerns around attending ED during the first 10 months of the 2020 COVID‐19 pandemic and frequently cited COVID‐19 as a reason for delaying their presentation. These factors would be amenable to mitigation via focussed public health messaging.

Preference for Visiting Emergency Department Over Primary Health Care Center Among Population in Saudi Arabia

Introduction

Demand for urgent care is increasing, and the pressure on emergency departments (EDs) is of significant concern. Demand growth is to some extent due to the over-utilization of EDs by patients who seek care for non-urgent problems. It has been estimated that up to one-third of all ED visits are non-emergent. In EDs, patients with non-urgent problems are blamed for increased demand, even though most of the patients’ reasons for attending EDs are not well studied. The aim of this study is primarily to determine the factors that influence the decision of patients to visit EDs instead of their primary care physician for non-urgent problems. Secondary aim of this study is to assess the level of ED knowledge among the participants. 

Methods

This is a descriptive, cross-sectional study following a convenient sampling technique conducted through an online questionnaire distributed to the population in Saudi Arabia (SA). The data, which includes sociodemographic data, ER knowledge, the correct definition of ED, cases that ED deals with, and reasons for visiting an ED over a primary health care center (PHC), were collected during August and September 2021.

Results

Of the 915 respondents, the most common age group was 25 years old or less (34.4%) and the majority were females (68.3%). It was observed that slightly more respondents preferred to visit a PHC (50.4%) while 49.6% preferred to visit EDs when having a medical condition. The proportion of respondents who would visit a PHC was 90.9%, and 36.6% indicated having good experiences there. The overall mean knowledge score was 4.63 (standard deviation [SD] 1.51) out of 6 points, with low, moderate, and high knowledge classified among 12.9%, 22.4%, and 64.7% of respondents, respectively. The five most reported reasons for choosing the ER as the preferred clinic over a PHC were: (1) ED provided quick medical care, (2) easy access to emergency care, (3) unavailability of appointments at a PHC center on the same day, (4) lack of full investigation at the PHC center, (5) lack of primary care providers at the PHC. The least reported reason was advice from another person to visit the emergency department. It was found that a significantly low knowledge was demonstrated by the over 45-years age group (p <0.001) and those who were unemployed (p = 0.018).

Conclusion

This study showed that 49.6% would prefer to visit the ED. It demonstrated the reasons for choosing the ED over a PHC, with the most reported reason being that the ED provides quick medical service, while the least reported reason was advice from another person to visit the ED. For the correct utilization of EDs, it is recommended to increase the knowledge and awareness level of the general population through public campaigns and awareness videos on social media applications.

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

Background

Studies have identified young adults as more likely to use emergency departments for ‘clinically unnecessary’ problems, with limited similar evidence for emergency ambulance use. Media portrayals depict young adults as motivated by ‘convenience’, but little research has explored the reasons for their help‐seeking behaviour.

Methods

Qualitative interviews with 16 young adults (18‐30) considered by clinicians to have made unnecessary use of emergency ambulance, emergency department or an urgent GP appointment. Data analysis was informed by interpretive phenomenological analysis.

Findings

A number of interrelated factors contributed to participants’ decisions. They were anxious about the seriousness of their symptoms, sometimes exacerbated by reduced coping capacity due to poor mental health or life stresses. They looked to others to facilitate their decision making, who sometimes encouraged urgent contact. They wanted to avoid impact on existing day‐to‐day commitments including work or study. They had strong views about different health services, sometimes based on frustration with lack of resolution of on‐going health problems. Convenience was not identified as a significant factor, although some actions could be interpreted in this light if the context was not considered.

Conclusions

Young adults make ‘clinically unnecessary’ use of urgent and emergency care for more than convenience. Their decisions need to be understood in relation to the complexity of their experience, including lack of confidence in making health‐related decisions, lowered coping capacity and concern to maintain normal daily life.

Does admission prevalence change after reconfiguration of inpatient services? An interrupted time series analysis of the impact of reconfiguration in five centres

Background

Service reconfiguration of inpatient services in a hospital includes complete and partial closure of all emergency inpatient facilities. The “natural experiment” of service reconfiguration may give insight into drivers for emergency admissions to hospital. This study addressed the question does the prevalence of emergency admission to hospital for children change after reconfiguration of inpatient services?

Methods

There were five service reconfigurations in Scottish hospitals between 2004 and 2018 where emergency admissions to one “reconfigured” hospital were halted (permanently or temporarily) and directed to a second “adjacent” hospital. The number of emergency admissions (standardised to /1000 children in the regional population) per month to the “reconfigured” and “adjacent” hospitals was obtained for five years prior to reconfiguration and up to five years afterwards. An interrupted time series analysis considered the association between reconfiguration and admissions across pairs comprised of “reconfigured” and “adjacent” hospitals, with adjustment for seasonality and an overall rising trend in admissions.

Results

Of the five episodes of reconfiguration, two were immediate closure, two involved closure only to overnight admissions and one with overnight closure for a period and then closure. In “reconfigured” hospitals there was an average fall of 117 admissions/month [95% CI 78, 156] in the year after reconfiguration compared to the year before, and in “adjacent” hospitals admissions rose by 82/month [32, 131]. Across paired reconfigured and adjacent hospitals, in the months post reconfiguration, the overall number of admissions to one hospital pair slowed, in another pair admissions accelerated, and admission prevalence was unchanged in three pairs. After reconfiguration in one hospital, there was a rise in admissions to a third hospital which was closer than the named “adjacent” hospital.

Conclusions

There are diverse outcomes for the number of emergency admissions post reconfiguration of inpatient facilities. Factors including resources placed in the community after local reconfiguration, distance to the “adjacent” hospital and local deprivation may be important drivers for admission pathways after reconfiguration. Policy makers considering reconfiguration might consider a number of factors which may be important determinants of admissions post reconfiguration.

Results of a National Text Message Poll of Youth: Perspectives on Primary Care

PURPOSE

There is a significant interest in improving adolescent access to primary care, yet limited attempts to incorporate youth feedback within these efforts. The purpose of this study was to describe the experiences related to primary care among a large national sample of adolescents to improve patient-centered care.

METHODS

Youth were sent open-ended text message prompts via an ongoing study of 14- to 24-year-olds in the U.S. Text responses were analyzed using qualitative thematic analysis, including descriptive coding, consensus building, and theme development. Secondary quantitative analyses were conducted to determine differences by demographics.

RESULTS

Of 1,123 eligible participants, 789 (70.2%) responded to at least one prompt. Four themes were developed: (1) youth recognized the importance of primary care, but barriers exist that limited their utilization; (2) youth felt that improving convenience would increase the use of primary care; (3) youth were unsure how to transition between primary care settings; and (4) feeling respected was essential to youth having positive experiences in a primary care health care setting. Older youth and those identifying as female, nonbinary, or transgender were more likely to report previous bad experiences with primary care.

CONCLUSIONS

Our findings describe barriers and possible solutions to primary care among youth. Because attitudes toward health and health care are established during adolescence, a transformation is needed to create more patient-centered care that aligns with young people's values and experiences. Thus, primary care providers have the opportunity to positively impact the health of young people today and the adults of the future.

Exploring Perceptions of Parents on the Use of Emergency Department On-site Primary Care Services for the Treatment of Children With Non-urgent Conditions

This study was conducted to understand the reasons parents of children with minor conditions attend the Children's Emergency Department (ED), and their views about onsite pediatric same day care (SDC) service as an alternative treatment center. The study was a cross-sectional survey of parents attending an inner-city, district general hospital children's ED, with children aged under 16 years old who were allocated to low triage categories. A convenience sample of 58 parents of 58 children were recruited. All the 58 responses were analyzed. Incomplete questionnaires were not excluded. 47% of attendances were because of minor injury. Most presentations were within 24 hours of the injury or illness. 72% of parents were employed. 91% were registered with a General Practitioner (GP). 29% contacted a GP before the ED visit. The majority of participants who contacted a GP were referred to the ED; others were advised to wait to see if the child's condition improved and to attend the ED if there were any concerns or the child deteriorated in any way. About 50% of those that did not contact GP said the GP surgery was closed and 8% felt the GP could not help. 90% of parents perceived their child's condition as urgent requiring immediate treatment. About 33% of parents said they would be happy for their children to be treated at an onsite SDC center. The study showed limited access to GP services in the community and dissatisfaction with community services and perceived urgency of treatment prompted parents of children with minor conditions to attend the ED. This could mean significant ED attendance by children with minor conditions. The majority of the parents in the study would welcome an onsite pediatric SDC if appropriate to meet their children's care needs. Establishing an onsite SDC may help relieve the ED pressures to attend to more clinically urgent and emergency cases.

Use Andersen's behavior model to explain non-urgent visits in emergency department: A single center study in southwest China

BACKGROUND

Non-urgent ED visit was an important contributor of emergency overcrowding. Previous studies showed that patients make non-urgent ED visits for many reasons and their ED use patterns may be influenced by many factors. However, seldom studies were theory-based research aimed to offer a systemic insight regarding this question.

METHODS

This was a cross-sectional study conducted in the ED of a tertiary hospital in China guided by Andersen's behavior model of health service use. Patients triaged as non-urgent were surveyed using a self-administrated questionnaire to investigate the reasons for ED presentation and associated factors influenced their ED use patterns.

RESULTS

Perceived severity of illness and urgent treatment need (374, 68.6%), accessible problems to alternative services (144, 26.4%) and referral by medical staffs (134, 24.6%) were most commonly reported reasons for ED presentation. Alternative service attempt before ED presentation was determined by two predisposing factors: education level (OR = 0.638, P < 0.05) and use of nearest medical institution (OR = 1.588, P < 0.05). Prior non-urgent ED use was explained by both predisposing and need factors. They were: nationality (OR = 3.057, P < 0.01), type of health problems (OR = 1.641, P < 0.01) and self-rated health status (OR = 0.769, P < 0.01).

CONCLUSION

Patients' perceived need of emergency care played an extremely important role in driving ED use although several factors were identified. Future studies aim to decrease non-urgent ED use in China may firstly gain success from patient education programs.

Epidemiology of non-deferrable medical conditions in primary care in Italy

Non-deferrable medical conditions (NDMC) are clinical entities other than exacerbations of chronic diseases which are too frequently managed by emergency departments. The primary care setting would be indeed the ideal environment to proficiently treat them. Few studies have investigated the epidemiology of NDMC in primary care, especially in Italy. With the aim to better identify NDMC sufferers, we assessed the accuracy of the NDMC definition by means of four algorithms, featured by different specificities and sensitivities. Four algorithms, based on the hierarchical definition of NDMC, were developed to calculate the incidence rate of NDMC in 2014. Each was tested using a Cox univariate model adjusted for gender, comparing patients aged <45 years old with older patients. Algorithms 1 and 3 gave similar results (408.1 vs. 405.5 per 1,000 person-years); Algorithms 2 and 4 reported sensibly lower rates (84.7 and 84.0 per 1,000 person-years). Incidence rate of NDMC for female patients was higher than in males and for older age group (i.e. 75-84 age group) than younger patients, for both gender groups. Regarding the regression model, a higher risk of NDMC was estimated in patients aged 45 years or more and in females. This study allowed us to assess the incidence rate of NDMC in Italy which was unexpectedly higher among older patients. Given the crucial role of general practitioners (GPs) in the diagnosis and management of these conditions, as well as the healthcare system reforms imposed by the ongoing financial crisis, our findings may contribute to informing the capacity and strategic workload planning in group of GPs to improve service quality and profitably to reduce the excessive use of emergency departments.

A conceptual model of urgent care sense-making and help-seeking: a qualitative interview study of urgent care users in England

Background

Theoretical models have sought to comprehend and conceptualise how people seek help from health professionals but it is unclear if such models apply to urgent care. Much previous research does not explain the complex interactions that influence how people make sense of urgent care and how this shapes service use. This paper aims to conceptualise the complexity of sense-making and help-seeking behaviour in peoples’ everyday evaluations of when and how to access modern urgent care provision.

Methods

This study comprised longitudinal semi-structured interviews undertaken in the South of England. We purposively sampled participants 75+, 18–26 years, and from East/Central Europe (sub-sample of 41 received a second interview at + 6–12 months). Framework analysis was thematic and comparative.

Results

The amount and nature of the effort (work) undertaken to make sense of urgent care was an overarching theme of the analysis. We distinguished three distinct types of work: illness work, moral work and navigation work. These take place at an individual level but are also shared or delegated across social networks and shaped by social context and time. We have developed a conceptual model that shows how people make sense of urgent care through work which then influences help-seeking decisions and action.

Conclusions

There are important intersections between individual work and their social networks, further shaped by social context and time, to influence help-seeking. Recognising different, hidden or additional work for some groups may help design and configure services to support patient work in understanding and navigating urgent care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4332-6) contains supplementary material, which is available to authorized users.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Background

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design

Mixed-methods sequential design.

Setting

Four counties in southern England coterminous with a NHS 111 provider area.

Methods

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration

This study is registered as UKCRN 32207.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?

OBJECTIVE

To understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively have been managed.

METHODS

Mixed methods service evaluation, including retrospective review of referrals to general paediatric outpatients (n=534) and a virtual integrated service (email advice line) (n=474), as well as a prospective survey of paediatric ambulatory unit (PAU) attendees (n=95) and review by a paediatric consultant/registrar to decide where these cases could alternatively have been managed.

RESULTS

The case mix of outpatient referrals and the email advice line was similar, but the case mix for PAU was more acute. The most common parental reasons for attending PAU were referral by a community health professional (27.2%), not being able to get a general practitioner (GP) appointment when desired (21.7%), wanting to avoid accident and emergency (17.4%) and wanting specialist paediatric input (14.1%). More than half of PAU presentations were deemed most appropriate for community management by a GP or midwife. The proportion of cases suitable for community management varied by the reason for attendance, with it highestl for parents reporting not being able to get a GP appointment (85%), and lowest for those referred by community health professionals (29%).

CONCLUSIONS

One in two attendances to acute paediatric services could have been managed in the community. Integration of paediatric services could help address parental reasons for attending acute services, as well as facilitating the community management of chronic conditions.

Examination of EMS Decision Making in Determining Suitability of Patient Diversion to Urgent Care Centers

Widespread use of Emergency Medicine Services (EMS) for non-emergency care has increased recently, causing overcrowding of the Emergency Department (ED). The increased availability of urgent care centers (UCCs), with their ability to see large numbers of unscheduled patients with more acute presentations, may offer a viable option for many EMS systems to divert non-emergent cases. Using a survey-based study combined with retrospective chart review, EMS provider ability to determine patient suitability for diversion to UCCs was assessed. Results indicated a rate of inappropriate diversion of 11.6%. UCCs may be an alternative option for EMS transport, however strict protocols with medical direction are needed.

Urgent Care Utilization in the Pediatric Medicaid Population

OBJECTIVE

To assess healthcare utilization patterns associated with high (≥3 visits/year) urgent care utilization.

STUDY DESIGN

Retrospective analysis of 2 723 792 children who were less than 19 years of age in the 2013 Marketscan Medicaid database. Healthcare utilization categorized as inpatient, emergency department, urgent care, well-child primary care provider (PCP), acute PCP, and specialist visits was documented for 4 groups. We hypothesized that children with high urgent care utilization would have decreased utilization at other sites of care. Multivariable logistic models compared the odds of high urgent care utilization.

RESULTS

Of children in the study population, 92.0% had no urgent care visits; 4.7% had 1; 1.5% had 2; and 1.0% had ≥3. Patient attributes of high urgent care utilization were: ages 1-2 years (aOR = 2.32, 95% CI: 2.18-2.36, reference group: 13-18 years), presence of a complex chronic condition (CCC) (aOR = 1.98, 95% CI: 1.88-2.07, reference group: no CCC) and no CCC but ≥3 chronic conditions (aOR = 2.85, 95% CI: 2.73-2.97, reference group: no CCC, no chronic conditions). High urgent care utilization was associated with ≥5 PCP visits for acute care (aOR = 1.16, 95% CI: 1.11-1.20, reference group: 0 visits), and ≥3 emergency department visits (aOR = 2.15, 95% CI: 2.10-2.23, reference group: 0 visits).

CONCLUSIONS

Increased urgent care utilization was associated with an increase in overall healthcare utilization. Even though those with higher urgent care utilization had more visits for acute care, patients continued to see their PCP for both well-child and acute care visits.

Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis

OBJECTIVES

Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.

METHODS

Systematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer-reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework-based narrative synthesis.

RESULTS

Thirty-eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty-nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency-based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations.

CONCLUSIONS

We identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.

Reasons for attending a general emergency outpatient clinic versus a regular general practitioner - a survey among immigrant and native walk-in patients in Oslo, Norway

OBJECTIVE

To explore reasons for attending a general emergency outpatient clinic versus a regular general practitioner (RGP).

DESIGN

Cross-sectional study using a multilingual anonymous questionnaire.

SETTING

Native and immigrant walk-in patients attending a general emergency outpatient clinic in Oslo (Monday-Friday, 08:00-23:00) during 2 weeks in September 2009.

SUBJECTS

We included 1022 walk-in patients: 565 native Norwegians (55%) and 457 immigrants (45%).

MAIN OUTCOME MEASURES

Patients' reasons for attending an emergency outpatient clinic versus their RGP.

RESULTS

Among patients reporting an RGP affiliation, 49% tried to contact their RGP before this emergency encounter: 44% of native Norwegian and 58% of immigrant respondents. Immigrants from Africa [odds ratio (OR) = 2.55 (95% confidence interval [CI]: 1.46-4.46)] and Asia [OR = 2.32 (95% CI: 1.42-3.78)] were more likely to contact their RGP before attending the general emergency outpatient clinic compared with native Norwegians. The most frequent reason for attending the emergency clinic was difficulty making an immediate appointment with their RGP. A frequent reason for not contacting an RGP was lack of access: 21% of the native Norwegians versus 4% of the immigrants claimed their RGP was in another district/municipality, and 31% of the immigrants reported a lack of affiliation with the RGP scheme.

CONCLUSIONS AND IMPLICATIONS

Access to primary care provided by an RGP affects patients' use of emergency health care services. To facilitate continuity of health care, policymakers should emphasize initiatives to improve access to primary health care services. KEY POINTS Access to immediate primary health care provided by a regular general practitioner (RGP) can reduce patients' use of emergency health care services. The main reason for attending a general emergency outpatient clinic was difficulty obtaining an immediate appointment with an RGP. A frequent reason for native Norwegians attending a general emergency outpatient clinic during the daytime is having an RGP outside Oslo. Lack of affiliation with the RGP scheme is a frequent reason for attending a general emergency outpatient clinic among immigrants.

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis

BACKGROUND

Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.

METHODS AND FINDINGS

Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care.

CONCLUSIONS

The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.

Pharmacist-led minor ailment programs: a Canadian perspective

Pharmacists have a long history of helping Canadians with minor ailments. This often has involved management with over-the-counter medications. If pharmacists felt that the best care required something more robust, they would refer the patient to a physician. In hopes of improving the care of such ailments, Canadian provinces have granted pharmacists the option of selecting medications traditionally under physician control. This review examines the Canadian perspective on pharmacists prescribing for minor ailments and the evidence of value for these programs. It might provide guidance for other jurisdictions contemplating such a move.

Is it a matter of urgency? A survey of assessments by walk-in patients and doctors of the urgency level of their encounters at a general emergency outpatient clinic in Oslo, Norway

Background

Emergency room (ER) use is increasing in several countries. Variability in the proportion of non-urgent ER visits was found to range from 5 to 90 % (median 32 %). Non-urgent emergency visits are considered an inappropriate and inefficient use of the health-care system because they may lead to higher expenses, crowding, treatment delays, and loss of continuity of health care provided by a general practitioner. Urgency levels of doctor–walk-in patient encounters were assessed based on their region of origin in a diverse Norwegian population.

Methods

An anonymous, multilingual questionnaire was distributed to all walk-in patients at a general emergency outpatient clinic in Oslo during two weeks in September 2009. We analysed demographic data, patient–doctor assessments of the level of urgency, and the results of the consultation. We used descriptive statistics to obtain frequencies with 95 % confidence interval (CI) for assessed levels of urgency and outcomes. Concordance between the patients’ and doctors’ assessments was analysed using a Kendall tau-b test. We used binary logistic regression modelling to quantify associations of explanatory variables and outcomes according to urgency level assessments.

Results

The analysis included 1821 walk-in patients. Twenty-four per cent of the patients considered their emergency consultation to be non-urgent, while the doctors considered 64 % of encounters to be non-urgent. The concordance between the assessments by the patient and by their doctor was positive but low, with a Kendall tau-b coefficient of 0.202 (p < 0.001). Adjusted logistic regression analysis showed that patients from Eastern Europe (odds ratio (OR) = 3.04; 95 % CI 1.60–5.78), Asia and Turkey (OR = 4.08; 95 % CI 2.43–6.84), and Africa (OR = 8.47; 95 % CI 3.87–18.5) reported significantly higher urgency levels compared with Norwegians. The doctors reported no significant difference in assessment of urgency based on the patient’s region of origin, except for Africans (OR = 0.64; 95 % CI 0.43–0.96).

Conclusion

This study reveals discrepancies between assessments by walk-in patients and doctors of the urgency level of their encounters at a general emergency clinic. The patients’ self-assessed perception of the urgency level was related to their region of origin.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-016-0086-1) contains supplementary material, which is available to authorized users.

Healthcare use among preschool children attending GP-led urgent care centres: a descriptive, observational study

OBJECTIVE

Urgent care centres' (UCCs) hours were developed with the aim of reducing inappropriate emergency department (ED) attendances in England. We aimed to examine the presenting complaint and outcomes of care in 2 general practitioner (GP)-led UCCs with extended opening times.

DESIGN

Retrospective observational epidemiological study using routinely collected data.

SETTING

2 GP-led UCCs in London, colocated with a hospital ED.

PARTICIPANTS

All children aged under 5 years, attending 2 GP-led UCCs over a 3-year period.

OUTCOMES

Outcomes of care for the children including: primary diagnosis; registration status with a GP; destination following review within the UCC; and any medication prescribed. Comparison between GP-led UCC visit rates and routine general practices was also made.

RESULTS

3% (n=7747/282 947) of all attenders at the GP-led UCCs were children aged under 5 years. The most common reason for attendance was a respiratory illness (27%), followed by infectious illness (17%). 18% (n=1428) were either upper respiratory tract infections or viral infections. The majority (91%) of children attending were registered with a GP, and over two-thirds of attendances were 'out of hours'. Overall 79% were seen and discharged home. Preschool children were more likely to attend their GP (47.0 per 100) than a GP-led UCC (9.4 per 100; 95% CI 8.9 to 10.0).

CONCLUSIONS

Two-thirds of preschool children attending GP-led UCCs do so out of hours, despite the majority being registered with a GP. The case mix is comparable with those presenting to an ED setting, with the majority managed exclusively by the GPs in the UCC before discharge home. Further work is required to understand the benefits of a GP-led urgent system in influencing future use of services especially emergency care.

Staff perceptions on patient motives for attending GP-led urgent care centres in London: a qualitative study

OBJECTIVES

General practitioner (GP)-led urgent care centres were established to meet the growing demand for urgent care. Staff members working in such centres are central in influencing patients' choices about which services they use, but little is known about staff perceptions of patients' motives for attending urgent care. We hence aimed to explore their perceptions of patients' motives for attending such centres.

DESIGN

A phenomenological, qualitative study, including semistructured interviews. The interviews were analysed using thematic content analysis.

SETTING

2 GP-led urgent care centres in 2 academic hospitals in London.

PARTICIPANTS

15 staff members working at the centres including 8 GPs, 5 emergency nurse practitioners and 2 receptionists.

RESULTS

We identified 4 main themes: 'Confusion about choices', 'As if increase of appetite had grown; By what it fed on', 'Overt reasons, covert motives' and 'A question of legitimacy'. The participants thought that the centres introduce convenient and fast access for patients. So convenient, that an increasing number of patients use them as a regular alternative to their community GP. The participants perceived that patients attend the centres because they are anxious about their symptoms and view them as serious, cannot get an appointment with their GP quickly and conveniently, are dissatisfied with the GP, or lack self-care skills. Staff members perceived some motives as legitimate (an acute health need and difficulties in getting an appointment), and others as less legitimate (convenience, minor illness, and seeking quicker access to hospital facilities).

CONCLUSIONS

The participants perceived that patients attend urgent care centres because of the convenience of access relative to primary care, as well as sense of acuity and anxiety, lack self-care skills and other reasons. They perceived some motives as more legitimate than others. Attention to unmet needs in primary care can help in promoting balanced access to urgent care.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey

Background

The annual number of unplanned attendances at accident and emergency (A&E) departments in England increased by 11% (2.2 million attendances) between 2008–2009 and 2012–2013. A national review of urgent and emergency care has emphasised the role of access to primary care services in preventing A&E attendances.

Aim

To estimate the number of A&E attendances in England in 2012–2013 that were preceded by the attending patient being unable to obtain an appointment or a convenient appointment at their general practice.

Design and setting

Cross-sectional analysis of a national survey of adults registered with a GP in England.

Method

The number of general practice consultations in England in 2012–2013 was estimated by extrapolating the linear trend of published data for 2000–2001 to 2008–2009. This parameter was multiplied by the ratio of attempts to obtain a general practice appointment that resulted in an A&E attendance to attempts that resulted in a general practice consultation estimated using the GP Patient Survey 2012–2013. A sensitivity analysis varied the number of consultations by ±12% and the ratio by ±25%.

Results

An estimated 5.77 million (99.9% confidence interval = 5.49 to 6.05 million) A&E attendances were preceded by the attending patient being unable to obtain a general practice appointment or a convenient appointment, comprising 26.5% of unplanned A&E attendances in England in 2012–2013. The sensitivity analysis produced values between 17.5% and 37.2% of unplanned A&E attendances.

Conclusion

A large number of A&E attendances are likely to be preceded by unsuccessful attempts to obtain convenient general practice appointments in England each year.

Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data

OBJECTIVE

To identify patient and attendance characteristics that are associated with onwards referral to co-located emergency departments (EDs) or other hospital specialty departments from general practitioner (GP) led urgent care centres (UCCs) in northwest London, England.

METHODS

We conducted a retrospective analysis of administrative data recorded in the UCCs at Charing Cross and Hammersmith Hospitals, in northwest London, from October 2009 to December 2012. Attendances made by adults resident in England were included. Logistic regression was used to model the associations between the explanatory variables-age; sex; ethnicity; socioeconomic status; area of residence; distance to UCC; GP registration; time, day, quarter, year; and UCC of attendance-and the outcome of onwards referral to the co-located EDs or other hospital specialty departments.

RESULTS

Of 243 042 included attendances, 74.1% were managed solely within the UCCs without same day referral to the EDs (16.8%) or other hospital specialty departments (5.7%), or deferred referral to a fracture, hand management or soft tissue injury management clinic (3.3%). The adjusted odds of onwards referral was estimated to increase by 19% (OR 1.19, 95% CI 1.18 to 1.19) for a 10 year increase in a patient's age. Men, patients registered with a GP and residents of less socioeconomically deprived areas were also more likely to be referred onwards from the UCCs.

CONCLUSIONS

The majority of patients, across each category of all explanatory variables, were managed solely within the UCCs, although a large absolute number of patients were referred onwards each year. Several characteristics of patients and their attendances were associated with the outcome variable.