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O’Cathain A, Knowles E, Long J, et al. Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study. Southampton (UK): NIHR Journals Library; 2020 Mar. (Health Services and Delivery Research, No. 8.15.)

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

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Appendix 3Relevance and context appraisal of included qualitative articles

TABLE 15

Relevance and context appraisal of included qualitative articles

Authors and year of publicationRelevance codeDefinition of sample/participants as described in the paper, and where description(s) can be found (title/abstract/methods)ServiceCommentsAdequacy of description of key aspects of context
ServiceGeographical settingDemographic details
Agarwal et al., 2012721

Title: ‘Potentially avoidable ED attendance’

Abstract: ‘could have been managed in an alternative service’

Methods: ‘Suitable to be cared for in an alternative urgent care provider service including primary care’/’attending the ED with urgent care needs that could be managed in other urgent care environments locally’

ED, two-thirds arriving by ambulance‘Non-urgent’ defined to include referral of relatively serious problems (e.g. chest pain, collapse) to a centre staffed by doctors, nurses and emergency practitionersYesNoYes
Ahl et al. 2006651

Methods: ‘had used ambulance care within the past 3 months . . . selected in order to achieve a large variation in . . . emergency priorities and medical diagnosis’

Background of 2012 paper: ‘pre-hospital care situations that are not defined as traumatic or life threatening’

AmbulanceYesPoorPoor
Becker et al. 1993442Methods: ‘adults with physician-diagnosed and documented asthma’, studying ‘individuals’ response to asthma’Mixed emergency/urgent care: service unclear, mostly EDPoorNoYes
Berry et al. 2008661

Title: ‘bring children to the ED for nonurgent conditions’

Abstract: ‘choosing the ED over their PCP for nonurgent paediatric care’

Methods: child ‘assigned a nurse triage level of 5 on a 1 to 5 scale (with 5 indicating “no resources likely to be utilized” or a non-urgent problem)’/brought child to ED ‘during hours when physicians’ offices are routinely open’

PEDYesYesYes
Booker et al. 2014731

Title: ‘call emergency ambulances for primary care problems’

Abstract: ‘called an ambulance for a primary care-appropriate health problem’

Methods: ‘likely to have been managed successfully in primary care’

AmbulanceYesNoYes
Brousseau et al. 2011451

Abstract: ‘presenting for non-urgent care at a children's hospital ED’

Methods: ‘triaged as nonurgent by the ED triage nurse’

PEDSome data relate to HCPs’ perceptionsYesNoYes
Calnan 1983461Methods: ‘minor condition . . . according to both the level of medical skill needed to treat the complaint and the facilities available to treat the condition’ – minor cuts ‘requiring cleaning and dressing only which could be carried out by a [nurse] alone’ – and minor illnesses ‘complaints of a non-traumatic nature which could have been treated by a GP’EDYesNoNo
Capp et al. 2016672Abstract: ‘Frequent ED users’ (4–18 visits in past year, if most visits not for mental health or substance abuse reasons)EDSample participating in RCT ‘to improve[e] primary care utilization’YesYesYes
Chin et al. 2006471

Title: ‘Nonurgent use of a PED’

Abstract: ‘presenting to a PED for nonacute care’

Methods: ‘in the PED whose visits were of low acuity as defined as score of 5 on 5 point Emergency Severity Index’

PEDSome data relate to HCPs’ perceptionsPoorPoorYes
de Bont et al. 2015482Methods: ‘presenting to the GP OOH centre with a febrile child under the age of 12’OOH – delivered by co-opYesYesYes
Durand et al. 201271

Title: ‘Nonurgent patients in ED’

Methods: ‘triaged as nonurgent upon their arrival to the ED by the triage nurse’, nonurgent defined as ‘problem could be taken care of by primary care physician’

EDSome data relate to HCPs’ perceptionsYesNoYes
Fieldston et al. 2012492

Title: ‘Nonurgent visits to the ED’

Methods: exploring and describing ‘reasons for nonurgent pediatric ED visits independent of a particular ED visit’

PEDSome data relate to HCPs’ perceptionsPoorYesYes
Goeman et al. 2004942

Title: ‘ED reattendance for asthma’

Methods: people with asthma not controlled by their current therapy who ‘reattended emergency departments within 12 months’

EDPart of a larger sample where others did not reattendYesPoorYes
Goepp et al. 2004852

Results: families from ‘among residents of the East Baltimore neighbour-hoods’ (area with high poverty levels)

Conclusions: ‘low-income patients, especially those belonging to minority groups’

Health service use, particularly PEDSome data ethnographic observations and community support workers’ perceptions and experiencesYesPoorPoor
Guttman et al. 2003501

Title: ‘Medically nonurgent ED visits’

Methods: visit ‘considered medically nonurgent’ by ED triage staff’

Adult and PEDYesPoorYes
Mostajer Haqiqi et al. 2016811Abstract: parents of child under 10 ‘seeking care for nontraumatic dental problems in the ED’ of a paediatric hospitalPEDYesYesYes
Hopton et al. 1996512Abstract: adults (or calling on behalf of another adult) or parents ‘who called their doctors out of hours’OOH – delivered by general practiceYesYesPoor
Houston and Pickering 2000522

Methods: parents of child under 10; three categories sampled: ‘Frequent users . . . used the service twice or more in the previous 6 months or four times or more in the previous year . . . One-off callers . . . one or more call in the past 6 months and none in the prior 3 years’

‘Non-callers . . . not used the service in the previous 3 years’

OOH – delivered by general practiceYesYesYes
Howard et al. 2005911

Title: ‘choosing the ED for non-urgent medical care’

Methods: ‘seeking treatment in the emergency department for care of a nonurgent complaint and who could articulate the reasons for choosing this source of care as opposed to their PCP’

EDYesYesYes
Hugenholtz et al. 2009532

Title: ‘seeking immediate primary care for their children’

Abstract: ‘ask for immediate medical attention for their children’

Methods: ‘had visited the cooperative with a sick child’. Most coded as U3 by triaging assistant ‘urgent, assess within several hours for medical or emotional reasons’ but, after examination, half needed no treatment or only advice about self-treatment

OOH – delivered by co-opSecond group purposively sampled – ‘children had required immediate referral to hospital care’ – to compare decision-making in two groupsYesPoorPoor
Hunter et al. 2013682Methods: ‘patients with one or more of four LTCs’ – chronic obstructive pulmonary disease, coronary heart disease, asthma and diabetesMixed emergency care: ED, WIC and OOHPoorPoorYes
Keizer Beache and Guell 2016821

Title: ‘Nonurgent accident and emergency department use’

Methods: ‘patients who had been triaged as non-urgent by the AED nurse’

EDYesYesYes
Koziol-McLain et al. 2000771

Title: ‘Seeking care for nonurgent medical conditions in the ED’

Methods: ‘discharged from the ED; and . . . triaged as nonurgent upon their arrival in the ED . . . based on a triage category of greater than 2 (triage categories range from 1 (life threatening) to 4)’

EDYesPoorPoor
Lawson et al. 2014922Methods: ‘patients with documented histories of asthma who were presenting with . . . asthma, shortness of breath, cough, or chest pain’EDYesPoorYes
MacKichan et al. 2017981Methods: ‘Patients who had self-referred to the ED, who attended the ED during GP practice opening hours, who had no investigations while at the ED and/or were discharged with “advice/guidance only”’EDSome data ethnographic observations and staff experiencesYesYesYes
McGuigan and Watson 2010541

Title: ‘Nonurgent attendance at EDs’

Methods: ‘non-urgent attenders who had been recorded as “self-referral” by receptionists at . . . ED . . . for whom the ED was the first choice for care’

EDPoorNoNo
Neill et al. 2016832

Abstract: ‘parents of children under five years, from a range of socioeconomic groups’

Methods: ‘parents in communities with differing social, economic and ethnic profiles’

Health service useYesYesYes
Olsson and Hansagi 2001692

Title: ‘Repeated use of the ED’

Methods: ‘frequent visitor’ defined as ‘a patient who has made four or more visits during the previous 12 months’, focusing on ‘patients who did not require particularly specialised medical care, which is why we used the patient database . . . for general surgery and internal medicine’ (i.e. not gynaecology, ENT, paediatric, psychiatry, etc.)

EDYesPoorYes
Shaw et al. 2013551

Title: ‘patients who use the ED for primary care needs’

Abstract: ‘patients who were discharged from the low acuity area of a university hospital ED’

Methods: ‘patients who sought treatment in the ED and were triaged to the non-urgent area’ based on the Emergency Severity Index – levels 4 and 5

EDYesPoorYes
Stafford et al. 2014561

Abstract: ‘inappropriate attendances at urgent care facilities’

Methods: ‘patients presenting to urgent care . . . diagnosed with simple mechanical back pain by their urgent care clinician’ and meeting the inclusion criterion of ‘requiring only advice and analgesia’

Mixed emergency/urgent care: ED, WIC and OOH servicePoorNoNo
Wilkin et al. 2012842Methods: members of a local community with ‘the second highest rates of calls to 911’ according to hospital data. Some of the participants ‘were identified as 911 users in a previous research project’EDNoYesYes
Woolfenden et al. 2000571

Title: ‘use of a paediatric ED as an ambulatory care service’

Methods: ‘parents of children who presented with non-urgent illnesses to a tertiary PED’

PEDYesNoPoor

HCP, health-care professional; OOH, out-of-hours primary care provision; PC, primary care; PED, paediatric emergency department.

Notes

Shaded boxes indicate aspects of context that are not adequately described. Where two or more aspects are shaded, the author/title column is also shaded to indicate that the paper has significant weaknesses in its description of context factors.

Relevance coding. 1: directly relevant, all papers included – aim relates to non-clinically necessary use; sample identified as non-clinically necessary users of urgent/emergency service. 2: partially relevant, all papers included – aim relates to non-clinically necessary use; sample identified as a group who tend to use urgent/emergency services when not clinically necessary (frequent users, people with long-term conditions, parents of young children, people with low social status), but not specifically non-urgent use in this instance.

Copyright © Queen’s Printer and Controller of HMSO 2020. This work was produced by O’Cathain et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK555096

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