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

Why do children under 5 years go to the GP in Lambeth: a cross-sectional study

OBJECTIVES

This study identifies the most common recorded reason for attendance to primary care for children under 5 years old, including a breakdown via age, ethnicity, deprivation quintile and sex.

DESIGN

Cross-sectional.

SETTING

39 of 40 general practices in Lambeth, London, UK.

PARTICIPANTS

22 189 children under 5 years who had attended primary care between the 1 April 2017 and 31 March 2020 and had not opted out of anonymous data sharing within Lambeth DataNet.

OUTCOME MEASURE

The primary objective was to identify the most frequently recorded complaint in general practice for children under 5 years old. The secondary objective was to understand how presenting complaint differs by age, ethnicity, sex and deprivation level. The third objective was to create a multivariate logistic regression with frequent attendance as the outcome variable.

RESULTS

Nine conditions formed over 50% of all patient interactions: the most common reason was upper respiratory tract infections (14%), followed by eczema (8%) and cough (7%). While there was some variation by ethnicity and age, these nine conditions remained dominant. Children living in the most deprived area are more likely to be frequent attenders than children living in the least deprived area (adjusted OR (AOR) 1.27 (95% CI 1.14 to 1.41)). Children of Indian (AOR 1.47 (1.04 to 2.08)), Bangladeshi (AOR 2.70 (1.95 to 3.74)) and other white (AOR 1.18 (1.04 to 1.34)) ethnicities were more likely to be frequent attenders, compared with those of white British ethnicity.

CONCLUSIONS

Most reasons for attendance for children under 5 years to primary care are for acute, self-limiting conditions. Some of these could potentially be managed by increasing access to community care services, such as pharmacies. By focusing on the influence of the broader determinants of health as to why particular groups are more likely to attend, health promotion efforts have the opportunity to reduce barriers to healthcare and improve outcomes.

A multimethod study of NHS 111 online

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.

Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits

Background

Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits.

Methods

We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category.

Results

There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults.

Conclusion

Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.

The Safety INdEx of Prehospital On Scene Triage (SINEPOST) study: The development and validation of a risk prediction model to support ambulance clinical transport decisions on-scene

One of the main problems currently facing the delivery of safe and effective emergency care is excess demand, which causes congestion at different time points in a patient’s journey. The modern case-mix of prehospital patients is broad and complex, diverging from the traditional ‘time critical accident and emergency’ patients. It now includes many low-acuity patients and those with social care and mental health needs. In the ambulance service, transport decisions are the hardest to make and paramedics decide to take more patients to the ED than would have a clinical benefit. As such, this study asked the following research questions: In adult patients attending the ED by ambulance, can prehospital information predict an avoidable attendance? What is the simulated transportability of the model derived from the primary outcome? A linked dataset of 101,522 ambulance service and ED ambulance incidents linked to their respective ED care record from the whole of Yorkshire between 1st July 2019 and 29th February 2020 was used as the sample for this study. A machine learning method known as XGBoost was applied to the data in a novel way called Internal-External Cross Validation (IECV) to build the model. The results showed great discrimination with a C-statistic of 0.81 (95%CI 0.79–0.83) and excellent calibration with an O:E ratio was 0.995 (95% CI 0.97–1.03), with the most important variables being a patient’s mobility, their physiological observations and clinical impression with psychiatric problems, allergic reactions, cardiac chest pain, head injury, non-traumatic back pain, and minor cuts and bruising being the most important. This study has successfully developed a decision-support model that can be transformed into a tool that could help paramedics make better transport decisions on scene, known as the SINEPOST model. It is accurate, and spatially validated across multiple geographies including rural, urban, and coastal. It is a fair algorithm that does not discriminate new patients based on their age, gender, ethnicity, or decile of deprivation. It can be embedded into an electronic Patient Care Record system and automatically calculate the probability that a patient will have an avoidable attendance at the ED, if they were transported. This manuscript complies with the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement (Moons KGM, 2015).

Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care

BACKGROUND

Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.

OBJECTIVE

To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.

METHODS

Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.

RESULTS

95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.

CONCLUSIONS

We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.

The Safety INdEx of Prehospital On Scene Triage (SINEPOST) study: the development and validation of a risk prediction model to support ambulance clinical transport decisions on-scene-a protocol

BACKGROUND

Demand for both the ambulance service and the emergency department (ED) is rising every year and when this demand is excessive in both systems, ambulance crews queue at the ED waiting to hand patients over. Some transported ambulance patients are 'low-acuity' and do not require the treatment of the ED. However, paramedics can find it challenging to identify these patients accurately. Decision support tools have been developed using expert opinion to help identify these low acuity patients but have failed to show a benefit beyond regular decision-making. Predictive algorithms may be able to build accurate models, which can be used in the field to support the decision not to take a low-acuity patient to an ED.

METHODS AND ANALYSIS

All patients in Yorkshire who were transported to the ED by ambulance between July 2019 and February 2020 will be included. Ambulance electronic patient care record (ePCR) clinical data will be used as candidate predictors for the model. These will then be linked to the corresponding ED record, which holds the outcome of a 'non-urgent attendance'. The estimated sample size is 52,958, with 4767 events and an EPP of 7.48. An XGBoost algorithm will be used for model development. Initially, a model will be derived using all the data and the apparent performance will be assessed. Then internal-external validation will use non-random nested cross-validation (CV) with test sets held out for each ED (spatial validation). After all models are created, a random-effects meta-analysis will be undertaken. This will pool performance measures such as goodness of fit, discrimination and calibration. It will also generate a prediction interval and measure heterogeneity between clusters. The performance of the full model will be updated with the pooled results.

DISCUSSION

Creating a risk prediction model in this area will lead to further development of a clinical decision support tool that ensures every ambulance patient can get to the right place of care, first time. If this study is successful, it could help paramedics evaluate the benefit of transporting a patient to the ED before they leave the scene. It could also reduce congestion in the urgent and emergency care system.

TRIAL REGISTRATION

This study was retrospectively registered with the ISRCTN: 12121281.

Impact of NHS 111 Online on the NHS 111 telephone service and urgent care system: a mixed-methods study

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.

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.