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Burns SK, Krishnamurti T, Doan TT, Hanmer J, Hoberman A, Kahn JM, Schweiberger K, Ray KN. Parent Perceptions of Telemedicine for Acute Pediatric Respiratory Tract Infections: Sequential Mixed Methods Study. JMIR Pediatr Parent 2024; 7:e49170. [PMID: 38227360 PMCID: PMC10828946 DOI: 10.2196/49170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/01/2023] [Accepted: 12/13/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Since 2020, parents have had increasing opportunities to use telemedicine for their children, but how parents decide whether to use telemedicine for acute pediatric care relative to alternative sites of care is not clear. One of the most common reasons parents seek acute care for their children is for acute respiratory tract infections (ARTIs). OBJECTIVE This study aims to examine parental expectations of care via telemedicine for pediatric ARTIs, contrasting expectations of care delivered via primary care telemedicine and direct-to-consumer (DTC) telemedicine. METHODS We performed a sequential mixed methods analysis to examine how parents assess telemedicine for their children's acute care. We used ARTIs as a case study for examining parent perceptions of telemedicine. First, we analyzed semistructured interviews focused on parent responses about the use of telemedicine. Each factor discussed by parents was coded to reflect whether parents indicated it incentivized or disincentivized their preferences for telemedicine versus in-person care. Results were organized by a 7-dimension framework of parental health care seeking that was generated previously, which included dimensions related to care sites (expected access, affordability, clinical quality, and site quality) and dimensions related to child or family factors (perceived illness severity, perceived child susceptibility, and parent self-efficacy). Second, we analyzed responses to a national survey, which inquired about parental expectations of primary care telemedicine, commercial DTC telemedicine, and 3 in-person sites of care (primary care, urgent care, and emergency department) across 21 factors identified through prior qualitative work. To assess whether parents had different expectations of different telemedicine models, we compared survey responses for primary care telemedicine and commercial DTC telemedicine using weighted logistic regression. RESULTS Interview participants (n=40) described factors affecting their perceptions of telemedicine as a care modality for pediatric ARTIs. Generally, factors aligned with access and affordability (eg, decreased wait time and lower out-of-pocket cost) were discussed as potential incentives for telemedicine use, while factors aligned with perceived illness severity, child susceptibility, and clinician quality (eg, trustworthiness) were discussed as potential disincentives for telemedicine use. In survey responses (n=1206), primary care and commercial DTC telemedicine were rated similarly on items related to expected accessibility and affordability. In contrast, on items related to expected quality of care, primary care telemedicine was viewed similarly to in-person primary care, while commercial DTC telemedicine was rated lower. For example, 69.7% (weighted; 842/1197) of respondents anticipated their children would be comfortable and cooperative with primary care telemedicine versus 49.7% (weighted; 584/1193) with commercial DTC telemedicine (P<.001). CONCLUSIONS In a mixed methods analysis focused on telemedicine for ARTIs, parents expressed more concerns about telemedicine quality in commercial DTC models compared with primary care-based telemedicine. These results could help health systems better design telemedicine initiatives to support family-centered care.
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Affiliation(s)
- Sarah K Burns
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tamar Krishnamurti
- Department of Medicine, University Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tran T Doan
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Janel Hanmer
- Department of Medicine, University Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jeremy M Kahn
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Hörauf JA, Schindler CR, Mühlenfeld N, Zabel J, Störmann P, Marzi I, Söhling N, Verboket RD. Who, When, Why?-Traumatological Patients in the Emergency Department of a Maximum Care Provider. Life (Basel) 2023; 13:2046. [PMID: 37895428 PMCID: PMC10607953 DOI: 10.3390/life13102046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Nationwide, there is an annual increase in the number of patients in German emergency departments resulting in a growing workload for the entire emergency department staff. Several studies have investigated the situation in emergency departments, most of which were interdisciplinary, but there are no data on a solely traumatological patient population. The present study therefore aims to investigate the situation in a university-based trauma surgery emergency department. A total of 8582 traumatological patients attending a university hospital from 1 January 2019 to 31 December 2019 were studied. Various variables, such as reason for presentation, time of accident, diagnosis, and diagnostic as well as therapeutic measures performed were analyzed from the admission records created. The mean age was 36.2 years, 60.1% were male, 63.3% presented on their own to the emergency department, and 41.2% presented during regular working hours between 8:00 a.m. and 6:00 p.m., Monday through Friday. The most common reason for presentation was outdoor falls at 17.4%, and 63.3% presented to the emergency department within the first 12 h after the sustained trauma. The most common diagnosis was bruise (27.6%), and 14.2% of patients were admitted as inpatients. Many of the emergency room patients suffered no relevant trauma sequelae. In order to reduce the number of patients in emergency rooms in the future, existing institutions in the outpatient emergency sector must be further expanded and effectively advertised to the public. In this way, the emergency medical resources of clinics, including staff, can be relieved to provide the best possible care for actual emergency patients.
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Affiliation(s)
- Jason-Alexander Hörauf
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (C.R.S.); (N.M.); (J.Z.); (P.S.); (I.M.); (N.S.); (R.D.V.)
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Sidhu M, Saunders CL, Davies C, McKenna G, Wu F, Litchfield I, Olumogba F, Sussex J. Vertical integration of general practices with acute hospitals in England: rapid impact evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-114. [PMID: 37839807 DOI: 10.3310/prwq4012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Background Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience. Objectives To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others. Design Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care. Results At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1-12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; p < 0.0001); outpatient attendances: 1% reduction (incidence rate ratio 0.99, 95% confidence interval 0.99 to 1.00; p = 0.0061), emergency inpatient admissions: 3% reduction (incidence rate ratio 0.97, 95% confidence interval 0.95 to 0.99; p = 0.0062) and emergency readmissions: 5% reduction (incidence rate ratio 0.95, 95% confidence interval 0.91 to 1.00; p = 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. The falls in accident and emergency department and outpatient attendance rates are temporary. Focus groups and interviews with staff (N = 22) and interviews with patients (N = 14) showed that with vertical integration, health service improvements are introduced following a period of cultural interchange. Patients with multiple long-term conditions continue to encounter 'navigation work' choosing and accessing health-care provision, with diminishing continuity of care. Limitations In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations. Conclusions Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach. Future research Further quantitative follow-up of the longer-term impact of vertical integration on hospital usage and more extensive interviewing of patients and their carers about patient experiences of navigating care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Manbinder Sidhu
- University of Birmingham, Health Services Management Centre, Birmingham, UK
| | - Catherine L Saunders
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Gemma McKenna
- University of Birmingham, Health Services Management Centre, Birmingham, UK
| | | | - Ian Litchfield
- University of Birmingham, Institute of Applied Health Research, Birmingham, UK
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Turnbull J, MacLellan J, Churruca K, Ellis LA, Prichard J, Browne D, Braithwaite J, Petter E, Chisambi M, Pope C. A multimethod study of NHS 111 online. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-104. [PMID: 37464813 DOI: 10.3310/ytrr9821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background NHS 111 online offers 24-hour access to health assessment and triage. Objectives This study examined pathways to care, differential access and use, and workforce impacts of NHS 111 online. This study compared NHS 111 with Healthdirect (Haymarket, Australia) virtual triage. Design Interviews with 80 staff and stakeholders in English primary, urgent and emergency care, and 41 staff and stakeholders associated with Healthdirect. A survey of 2754 respondents, of whom 1137 (41.3%) had used NHS 111 online and 1617 (58.7%) had not. Results NHS 111 online is one of several digital health-care technologies and was not differentiated from the NHS 111 telephone service or well understood. There is a similar lack of awareness of Healthdirect virtual triage. NHS 111 and Healthdirect virtual triage are perceived as creating additional work for health-care staff and inappropriate demand for some health services, especially emergency care. One-third of survey respondents reported that they had not used any NHS 111 service (telephone or online). Older people and those with less educational qualifications are less likely to use NHS 111 online. Respondents who had used NHS 111 online reported more use of other urgent care services and make more cumulative use of services than those who had not used NHS 111 online. Users of NHS 111 online had higher levels of self-reported eHealth literacy. There were differences in reported preferences for using NHS 111 online for different symptom presentations. Conclusions Greater clarity about what the NHS 111 online service offers would allow better signposting and reduce confusion. Generic NHS 111 services are perceived as creating additional work in the primary, urgent and emergency care system. There are differences in eHealth literacy between users and those who have not used NHS 111 online, and this suggests that 'digital first' policies may increase health inequalities. Limitations This research bridged the pandemic from 2020 to 2021; therefore, findings may change as services adjust going forward. Surveys used a digital platform so there is probably bias towards some level of e-Literacy, but this also means that our data may underestimate the digital divide. Future work Further investigation of access to digital services could address concerns about digital exclusion. Research comparing the affordances and cost-benefits of different triage and assessment systems for users and health-care providers is needed. Research about trust in virtual assessments may show how duplication can be reduced. Mixed-methods studies looking at outcomes, impacts on work and costs, and ways to measure eHealth literacy, can inform the development NHS 111 online and opportunities for further international shared learning could be pursued. Study registration This study is registered at the research registry (UIN 5392). Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Turnbull
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jennifer MacLellan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kate Churruca
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Louise A Ellis
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Jane Prichard
- School of Health Sciences, University of Southampton, Southampton, UK
| | | | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Emily Petter
- NHS Hampshire, Southampton and Isle of Wight Clinical Commissioning Group, Winchester, UK
| | - Matthew Chisambi
- Imperial College Health Partners, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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5
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Pope C, MacLellan J, Prichard J, Turnbull J. The remarkable invisibility of NHS 111 online. SOCIOLOGY OF HEALTH & ILLNESS 2023; 45:772-790. [PMID: 36447404 DOI: 10.1111/1467-9566.13591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/09/2022] [Indexed: 05/04/2023]
Abstract
In 2017, the NHS 111 telephone service was augmented by an online service. This is an exemplar of 'digital-first', the push to enrol digital technologies to deliver services, and is viewed by policymakers as an important vehicle for managing demand for overburdened health services. This article reports the qualitative component of a larger multi-method study of NHS 111 online. Qualitative telephone interviews with 80 staff and stakeholders implicated in primary, urgent and emergency care service delivery explored the impact of NHS 111 online on health-care work. The analysis presented here draws on Susie Scott's work on the 'sociology of nothing' and theories of the marked and unmarked, which we reached for when confronted by the remarkable invisibility of this seemingly core NHS service in the wider landscape of health care. Despite the apparently high use by patients and the public (30 million visits over 6 months in the 2020 pandemic), we were surprised to find very low awareness among our interviewees. Confusion about nomenclature, an exceedingly crowded digital field (littered with alternative technologies and ways of accessing care) and constant change in service provision provide some cogent reasons for this invisibility, and sociology helps explain our data about this digital technology.
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Affiliation(s)
- Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jennifer MacLellan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jane Prichard
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Joanne Turnbull
- School of Health Sciences, University of Southampton, Southampton, UK
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Ogueji IA, Okoloba MM. Seeking Professional Help for Mental Illness: A Mixed-Methods Study of Black Family Members in the UK and Nigeria. PSYCHOLOGICAL STUDIES 2022; 67:164-177. [PMID: 35578647 PMCID: PMC9094119 DOI: 10.1007/s12646-022-00650-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 02/10/2022] [Indexed: 11/27/2022] Open
Abstract
Seeking professional help for mental illness is a limited practice among Black family members in low and middle socioeconomic groups in the United Kingdom (UK) and Nigeria. Guided by the theory of planned behavior, we explored some factors restricting professional help-seeking practices among the target groups. This mixed-methods study recruited a heterogeneous sample of 105 ( ranging from 19–64 years) UK and Nigerian Black family members in low or middle socioeconomic groups. Data were collected using a standardized questionnaire and open-ended questions. Collected data were analyzed using IBM SPSS statistics (version 22.0) and thematic analysis. There was no statistically significant difference in professional help-seeking behavior among the UK and Nigerian Black family members in low and middle socioeconomic groups [F (3, 83) = 1.13; p > .05]. The qualitative data analysis revealed that respondents were limited from professional help-seeking due to high consultation fees to see a mental health professional, perceived accessibility to mental health services within their various locations, stigmatization and socio-cultural factors (such as, “The perception that a man should be strong” or “Mental health isn’t as important as physical health”), concerns about the safety of information shared during professional help-seeking or therapy sessions, poor knowledge about mental health services, long waiting time to see a professional in face-to-face therapy, and risk of contracting the infectious disease in the hospital setting. Implications of findings for theory and practice and direction for future research are thus discussed.
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Affiliation(s)
| | - Maia Makeda Okoloba
- Department of Psychology, The University of Buckingham, Yeomanry House, Buckingham, Buckinghamshire MK18 1EG UK
- South West London and St. George’s Mental Health NHS Trust, London, UK
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Turner J, Knowles E, Simpson R, Sampson F, Dixon S, Long J, Bell-Gorrod H, Jacques R, Coster J, Yang H, Nicholl J, Bath P, Fall D. Impact of NHS 111 Online on the NHS 111 telephone service and urgent care system: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background
The NHS emergency and urgent care system is under pressure as demand for services increases each year. NHS 111 is a telephone triage service designed to provide advice and signposting to appropriate services for people with urgent health-care problems. A new service, NHS 111 Online, has been introduced across England as a digital alternative that can be accessed using a website or a smartphone application. The effects and usefulness of this service are unknown.
Objectives
To explore the impact of NHS 111 Online on the related telephone service and urgent care system activity and the experiences of people who use those services.
Design and methods
A mixed-methods design of five related work packages comprising an evidence review; a quantitative before-and-after time series analysis of changes in call activity (18/38 sites); a descriptive comparison of telephone and online services with qualitative survey (telephone, n = 795; online, n = 3728) and interview (32 participants) studies of service users; a qualitative interview study (16 participants) of staff; and a cost–consequences analysis.
Results
The online service had little impact on the number of triaged calls to the NHS 111 telephone service. For every 1000 online contacts, triaged telephone calls increased by 1.3% (1.013, 95% confidence interval 0.996 to 1.029; p = 0.127). Recommendations to attend emergency and urgent care services increased between 6.7% and 4.2%. NHS 111 Online users were less satisfied than users of the telephone service (50% vs. 71%; p < 0.001), and less likely to recommend to others (57% vs. 69%; p < 0.001) and to report full compliance with the advice given (67.5% vs. 88%; p < 0.001). Online users were less likely to report contacting emergency services and more likely to report not making any contact with a health service (31% vs. 16%; p < 0.001) within 7 days of contact. Thirty-five per cent of online users reported that they did not want to use the telephone service, whereas others preferred its convenience and speed. NHS 111 telephone staff reported no discernible increase or decrease in their workload during the first year of operation of NHS 111 Online. If online and telephone services operate in parallel, then the annual costs will be higher unless ≥ 38% of telephone contacts move to online contacts.
Conclusions
There is some evidence that the new service has the potential to create new demand. The service has expanded significantly, so it is important to find ways of promoting the right balance in numbers of people who use the online service instead of the telephone service if it is to be effective. There is a clear need and preference by some people for an online service. Better information about when to use this service and improvements to questioning may encourage more uptake.
Limitations
The lack of control arm means that impact could have been an effect of other factors. This work took place during the early implementation phase, so findings may change as the service expands.
Future work
Further development of the online triage process to make it more ‘user friendly’ and to enable users to trust the advice given online could improve use and increase satisfaction. Better understanding of the characteristics of the telephone and online populations could help identify who is most likely to benefit and could improve information about when to use the service.
Trial registration
Current Controlled Trials ISRCTN51801112.
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. 9, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rebecca Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona Sampson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jaqui Long
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Bell-Gorrod
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hui Yang
- School of Information Studies, University of Sheffield, Sheffield, UK
| | - Jon Nicholl
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Peter Bath
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
- School of Information Studies, University of Sheffield, Sheffield, UK
| | - Daniel Fall
- Sheffield Emergency Care Forum, Sheffield, UK
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Long J, Knowles E, Bishop-Edwards L, O'Cathain A. Understanding young adults' reasons for seeking 'clinically unnecessary' urgent and emergency care: A qualitative interview study. Health Expect 2021; 24:1535-1544. [PMID: 34118177 PMCID: PMC8369113 DOI: 10.1111/hex.13301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/03/2021] [Accepted: 05/27/2021] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Jaqui Long
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Alicia O'Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Miller S, Gilbert S, Virani V, Wicks P. Patients' Utilization and Perception of an Artificial Intelligence-Based Symptom Assessment and Advice Technology in a British Primary Care Waiting Room: Exploratory Pilot Study. JMIR Hum Factors 2020; 7:e19713. [PMID: 32540836 PMCID: PMC7382011 DOI: 10.2196/19713] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/11/2020] [Accepted: 06/14/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND When someone needs to know whether and when to seek medical attention, there are a range of options to consider. Each will have consequences for the individual (primarily considering trust, convenience, usefulness, and opportunity costs) and for the wider health system (affecting clinical throughput, cost, and system efficiency). Digital symptom assessment technologies that leverage artificial intelligence may help patients navigate to the right type of care with the correct degree of urgency. However, a recent review highlighted a gap in the literature on the real-world usability of these technologies. OBJECTIVE We sought to explore the usability, acceptability, and utility of one such symptom assessment technology, Ada, in a primary care setting. METHODS Patients with a new complaint attending a primary care clinic in South London were invited to use a custom version of the Ada symptom assessment mobile app. This exploratory pilot study was conducted between November 2017 and January 2018 in a practice with 20,000 registered patients. Participants were asked to complete an Ada self-assessment about their presenting complaint on a study smartphone, with assistance provided if required. Perceptions on the app and its utility were collected through a self-completed study questionnaire following completion of the Ada self-assessment. RESULTS Over a 3-month period, 523 patients participated. Most were female (n=325, 62.1%), mean age 39.79 years (SD 17.7 years), with a larger proportion (413/506, 81.6%) of working-age individuals (aged 15-64) than the general population (66.0%). Participants rated Ada's ease of use highly, with most (511/522, 97.8%) reporting it was very or quite easy. Most would use Ada again (443/503, 88.1%) and agreed they would recommend it to a friend or relative (444/520, 85.3%). We identified a number of age-related trends among respondents, with a directional trend for more young respondents to report Ada had provided helpful advice (50/54, 93%, 18-24-year olds reported helpful) than older respondents (19/32, 59%, adults aged 70+ reported helpful). We found no sex differences on any of the usability questions fielded. While most respondents reported that using the symptom checker would not have made a difference in their care-seeking behavior (425/494, 86.0%), a sizable minority (63/494, 12.8%) reported they would have used lower-intensity care such as self-care, pharmacy, or delaying their appointment. The proportion was higher for patients aged 18-24 (11/50, 22%) than aged 70+ (0/28, 0%). CONCLUSIONS In this exploratory pilot study, the digital symptom checker was rated as highly usable and acceptable by patients in a primary care setting. Further research is needed to confirm whether the app might appropriately direct patients to timely care, and understand how this might save resources for the health system. More work is also needed to ensure the benefits accrue equally to older age groups.
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10
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O’Cathain A, Knowles E, Long J, Connell J, Bishop-Edwards L, Simpson R, Coster J, Abouzeid L, Bennett S, Croot E, Dickson JM, Goodacre S, Hirst E, Jacques R, Phillips M, Turnbull J, Turner J. Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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.
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Affiliation(s)
- Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jaqui Long
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janice Connell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Rebecca Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Elizabeth Croot
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jon M Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Enid Hirst
- Sheffield Emergency Care Forum, Sheffield, UK
| | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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