Coster, J.E. orcid.org/0000-0002-0599-4222, Turner, J.K., Bradbury, D. et al. (1 more author) (2017) Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Academic Emergency Medicine. ISSN 1069-6563
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general population in rural and urban areas. The voluntary participation of participants may have been influenced by personal interest. Participants’ perception of their home town’s hospital emergency and/or urgent care services may be different from others in the same geo- graphic location. Data collection may also have been influenced by differences in unequal sample size. Only 61 of 176 college-age participants were rural residents. Demographic variables were not collected on age, class standing, race and ethnicity, and these may have skewed the findings. Misreading and misinterpretation of survey questions by participants are well noted. For example, one of the survey questions asked about the time (in minutes) it took for partici- pants to travel from home to an ED or UCC for medical care. However, it is likely participants misread and misinterpreted the question to read how long it took for them drive there, waiting Table 2: Cross-Tabulation of Perceived Differences Among Rural and
NHS 111 had the potential to produce an impact on activity across a range of emergency and urgent care ser- vices: calls to the emergency ambulance service; ambu- lance incidents, that is, an ambulance is sent and arrives at the scene of the emergency incident; ED attendances; contacts with urgent care services such as GP out of hours, urgent care centres, walk in centres or minor injury units; the telephone triage service NHS Direct; same day general practice attendances; and a range of community services such as district nursing, dentists and pharmacies. Data are routinely available for ambulance calls and incidents ED, urgent care and NHS Direct by residents in the seven geographical areas — four pilot and three control sites — for 24 months prior to the start of NHS 111 (2008 – 2010) and the same data plus calls to NHS 111 in the pilot areas for 12 months after (2010 – 2011). Owing to a lack of data availability for separate urgent care services, we had to combine data for out-of-hours primary care contacts, walk-in centre atten- dances and urgent care centre attendances. The sources of this data were NHS data collections (secondary users service and weekly situation reports) and local manage- ment information reports provided by the study sites. For local management information reports a set of data items and de ﬁ nitions was used to standardise data collec- tion across all sites. In one pilot area data on one urgent care contact data item was missing and therefore input- ted from the previous and subsequent 3 months activity. All data were collected and collated by the Department of Health commissioning analysis and intelligence team.
There are several limitations to this study. Perhaps most importantly, patients surveyed were those seeking care in our UCC at least once during the study period, rather than a population-based study in which a random sample of community residents were interviewed about their urgent care needs. In addition, there was no demographic infor- mation available on survey nonrespondents, although comparison of the study patient population to all users of the clinic during the study period demonstrated similarity in age, race/ethnicity, gender, and insurance status. Because of the methodology used, we were only able to verify patients' self-reported prior health care use if it had occurred at our institution. We were also unable to objec- tively determine the urgency of a patient's presenting complaint and/or their need as perceived by health care professionals to access urgent care services. This study was conducted during the summer months, so there may be unique seasonal variations in care-seeking behaviors that cannot be analyzed here. We intentionally avoided con- ducting the study during the busy flu season because we knew it would be a confounder for accessing urgent care. In our health care system there is a standard method of triage between patients seeking care in the ED and UCC so that during the study period all urgent care appropriate patients were seen in the urgent care and eligible for study inclusion. However, we made no attempt to assess where the patient first attempted to seek care (presenting directly to the urgent care or triaged there from the ED); there may
Our findings resonate with existing literature [24, 49] but illuminate the social processes relevant to urgent and emergency care help-seeking. We have shown that service users hold strong moral views and are highly sensitive to arguments about ‘inappropriate’ help- seeking in the emergency department. However, they often externalise these judgements such that moral rules are applied to others (e.g. characterising others as ‘time wasters’) [10, 23, 27]. We observed fewer moral judge- ments regarding the ‘misuse’ of urgent care services and this seems to reflect the dominance in public discourse about ‘overcrowded’ emergency departments and the idea that such services are sanctioned as needing to be available to all comers. We have also shown that people make choices influenced by what is accessible at a given time of day [25, 48]. Urgent care provision is variable, and there is inconsistency in provision across different areas. Waiting time is a strong factor in decision making. National Audit Office figures suggest that patients regis- tered with general practices that are open fewer than 45 h per week attend the emergency department more often . Road and transport links may further influ- ence accessibility of some services  and our data sug- gests that proximity is temporal as well as geographical (e.g. the hospital may be ‘nearer’ at night because of car and motorway access). These temporal and spatial fea- tures are highly socially patterned: older people for ex- ample relied more on others for transport than other groups, recent East European migrants may have less knowledge of services in their locality and this will limit their choices.
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Aim: To identify the appropriate service provider attendees of emergency departments (EDs) and walk-in centres (WiCs) in North East London and to match this to local service provision and patient choice. Design: An anonymous patient survey and a retrospective analysis of a random sample of patient records were performed. A nurse consultant, general practitioner (GP) and pharmacist used the presenting complaints in the patients’ records to independently stream the patient to primary care services, non-National Health Services or ED. Statistical analysis of level of agreement was undertaken. A stakeholder focus group reviewed the results. Subjects and setting: Adult health consumers attending ED and urgent care services in North East London. Results: The health user survey identified younger rather than older users (mean age of 35.6 years – SD 15.5), where 50% had not seen a health professional about their concern, with over 40% unable to obtain a convenient or emergency appointment with their GP. Over a third of the attendees were already receiving treatment and over 40% of these saw their complaint as an emergency. Over half of respondents expected to see a doctor, one-quarter expected to see a nurse and only 1% expected to see a pharmacist across both services, although WiCs are nurse-led services. More respondents expected a prescription from a visit to a WiC, whereas in the ED a third of respondents sought health advice or reassurance. Conclusion: A number of unscheduled care strategies are, or have just been, developed with the emphasis on moving demand into community-based services. Plurality of services provides service users with a range of alternative access points but can cause duplication of services and repeat attendance. Managing continued increase in emer- gency and unscheduled care is a challenge. The uncertainties in prospective decision making could be used to inform service development and delivery.
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The Indian health-care system has diverse ironies. We are debatably one of the premium health care in the world, but it is not uniformly accessible to all citizens. Nowadays, global aging and the pervasiveness of chronic diseases have become a widespread distress. Majority of our citizens are uninsured Indians, many uninsurable patients are so in poor health that insurance companies refuse them completely or charge unaffordable high premiums. As a prosperous country with enormous resources, India is in an exclusive position to set an example provided that all its citizens have access to excellent health care. The present health-care problems can be solved by a new system that transforms medical care away from the hospital into a community clinic. Several countries are enduring hospital improvement by dropping the number of hospital beds and rising percentage of home healthcare. Patients and their chief care donors then utilize telemedicine above a distributed network to link to tertiary medical providers and systems worldwide. An upcoming trend in healthcare is to shift routine medical checks and other healthcare services from hospital to the home conditions.
The sampling strategy involved purposive sequential enrolment of patients with histologically proven cervical cancer as they became available at the facility till the required sample size was reached. Healthcare workers were also purposively sampled for key informant interview. Only those who consented were sampled. The healthcare providers in charge of the patients and palliative care specialist helped identify patients based on information in the patient files then referred them to the researcher who confirmed their eligibility and proceeded to seek consent from each of them. This exercise was done every day in the gynecological ward (ward 4) and in room 19/16 where cervical cancer screening, cryotherapy and LEEP was performed. Patients were also selected on Tuesdays in the gynecological outpatient clinics (GOPC) where patients who were diagnosed at early stage were done for surgery. This was done until the desired sample size (334) was achieved. Participants for in-depth interviews were selected by the care providers based on how long they had been symptomatically sick (at least more than one year) and consented to the study. Pilot survey was conducted at the neighboring Kisumu East sub-county hospital to test the study tools and improve their quality and efficiency.
means that history and past politics have been important to the development of emergency care in hospitals. Nevertheless, it is hoped that activity based funding will be introduced at some stage in this area. Although activ- ity based funding is commonly used to fund acute hos- pital care, there is not a large body of research about the impact of this funding mechanism on efficiency, particu- larly in emergency and urgent care , and the findings vary between countries and contexts  . Further re- search on costs, cost-effectiveness and the implications of various staff-mix configurations are needed to ensure that activity based funding captures the complexity of cases treated in ED and urgent care settings appropri- ately . There may also be potential for more integra- tion of services through the relatively new hospital networks. Ambulance services are funded separately for National Ambulance Services (outside of Dublin) and the Dublin Fire Brigade (within Dublin). GPs are entirely private sector agents but are funded by Government through a contract for those patients who have medical cards. Their contract is based on a mix of per capita pay- ments and fee for services . The out of hours and emergency care that they provide for medical card pa- tients is funded on a fee for service basis by Government. Private patients (around 60% of the population) who wish to receive such care, must pay the full costs. Individuals who wish to seek private emergency care may do so in the major cities, according to their own means and private in- surance status.
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our finding that almost half of the ED visits were the lowest severity categories, either level 1 or 2 severity. If the lowest acuity patients could be seen in a lower acuity setting, such as the UC, this shift could decrease the overutilization of the ED. Previous studies have shown that care for low-acuity diagnoses in nonhospital-based ambulatory settings is comparable in quality to that in EDs and can be provided at a lower cost. 6 Ideally patients would
Eight health care packages covering a total of 134 primary level and 164 hospital level interventions were de- fined for the maternal and perinatal program 2 : 1) Accessibility: knowledge of the health care staff and popula- tion about the Healthy Pregnancy strategy (Embarazo Saludable) and the General Agreement on Inter-institu- tional Collaboration for Obstetric Emergency Care (Convenio General de Colaboración Interinstitucional para la Atención de Emergencias Obstétricas) as well as no physical, economic and cultural barriers to accessing health facilities; 2) Prenatal care: interventions aimed at identifying the skills and competencies needed to treat urinary infections and to determine risk factors for preeclampsia and hemorrhage. Other packages that represent some of the new challenges in prenatal care were included separately, such as the next three; 3) HIV-STI in Pregnancy: universal access to antiretroviral medication, adequate prevention campaigns and prevention of vertical trans- mission; 4) Syphilis: resources needed to perform the VDRL blood test for syphilis as well as early treatment; 5) Influenza in Pregnancy: early detection of cases, detection of complications and case referrals, adequate treat- ment, sufficient and adequate information aimed at the general public; 6) Delivery Care: a) the availability of supplies and instruments, b) the basic knowledge needed to provide medical attention as indicated by norms and
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Notes: Positive outcome: reviews showing positive trends or significant (P , 0.05) improvements associated with integrated care models. Negative outcome: reviews showing insignificant (P,0.05) improvements associated with integrated care models. NA: reviews that do not examine this outcome. Twenty-seven systematic reviews were identified for the meta-analysis of the integrated care conditions for adults with chronic conditions, including chronic heart failure (12 reviews), diabetes mellitus (7 reviews), COPD (7 reviews), and asthma (5 reviews). Most reviews show that integrated care models do have beneficial impacts on the clinical and functions results for the patients, the patients’ overall experience, care process, and health care resources usage. Specifically, there is a significant reduction in hospital admission and readmission for patients with chronic heart failure and diabetes, improvement in adherence to treatment guidelines in patients with diabetes, COPD, and asthma, and increase in quality of life in patients with diabetes. Data from Martínez-González et al. 6
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New parents with young children in child care should be given regular antic- ipatory guidance regarding the expected increase in frequency of infections and the management of common child care related illnesses. Targeted parent educa- tional interventions in child care could help decrease the demand for antibiotics for viral or respiratory conditions. It is unclear how implementation of the Affordable Care Act (ACA) may affect health care-seeking behavior of parents for children in child care. In this study and others, most families have primary care providers for their child, and expansion of children ’ s coverage is not a major focus of the ACA. The ACA ’ s emphasis on
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using only telephone. These issues reduce the data available to the treating DTC telemedicine provider, which may be of greater concern in pediatric care because of the more limited ability of children to communicate symptoms. Second, there may be differential expectations for antibiotics among children and parents who use DTC telemedicine versus in-person care. Although we matched on a number of observed variables, parental expectations may still differ across settings in ways that we were unable to address. Third, DTC telemedicine visits outside of the medical home lack 3 types of continuity: informational (lack of medical records), relationship (lack of ongoing relationship between the provider and patient), and clinical management (lack of opportunity to manage the patient’s care over time), 34 which has the potential to impact quality of care. However, this is unlikely to be the only explanation given that authors of previous evaluations of retail-based clinics, which are also a model of in-person care with limited continuity, have found comparable quality to
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Addressing sexual and reproductive health among youth is central in reducing childhood and maternal morbidity and mortality embedded in the fourth and fifth Millennium Development Goals. We have found that, despite the high rate of sexual activity and knowledge on contraception among undergraduate students, the rate of contraceptive use among female university students is still low, and the main source of getting reproductive health information is friends. There is an urgent need for understanding why university students are not utilizing the services offered at existing facilities within their universities, and also a need for aggressive advocacy of adolescent reproductive health before initiation of sexual activity and dissemination of information on family plan- ning methods among the adolescent population, as well as the university students in Tanzania. Intensive education on contraceptive use should be provided at a much earlier level of education, ie, during primary school and secondary school, before the adolescents are sexually active.
insignificant associations between total KAT score and university type, employment status, pharmacy or hospital location area, and primary obstacles in pharmaceutical care services (P.0.05). There were significant associations between the pharmacist type and some of KAT questions (3, 7, 11, 14, 16, 17, 19, 20, 21, and 23, P,0.05). The results showed that the registered pharmacists had a higher cor- rect answer response for these questions than unregistered pharmacists. Table 4 shows the percentage of correct response and incorrect response of each question of KAT among the sample population.
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Measurement of the use of health care services provided during the first weeks postpartum is needed to model the cost and consequences of early discharge. Some additional planned services, such as early follow-up at home or in clinics and offices, may be necessary to compensate for reduced in- hospital monitoring and education. Our finding that the frequency of infant urgent care visits did not increase may be attributable to the planned additional care provided under ROLOS, such as primary care follow-up, provider-initiated phone calls and home visits. Evidence in the literature suggests that home visits after early discharge im- prove outcomes. 15 Primary care office visits after
potential impact of pharmacists in A&E, very few programs existed in which pharmacists undertake this role. In response to a survey, 99% of medical and nursing respondents in departments with a pharmacist (82% return rate) felt the A&E pharmacist improved quality of care, 96% believed them to be an integral part of the team, and 93% reported consulting the pharmacist at least a few times during their last five shifts. While there was willingness by physicians and nurses to accept a pharmacist within the A&E team, the role described within the USA was primarily limited to medica- tion history taking with minimal other direct patient care. 8,9
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Pediatric urgent care centers see a wide range of pa- tient acuity and often provide care that encompasses some services normally administered in the primary care office and some traditionally provided in the emergency department. Pediatric urgent care providers are often ex- pected to be competent in fracture management, wound care, abscess drainage and IV placement. In addition, be- tween 1 and 5% of patients who initially present to an UCC will subsequently require transport to an emer- gency department ; consequently, an urgent care pro- vider must be competent to provide stabilization of critically ill children prior to the availability of transport
A number of arguments been offered for the need for community based services that fill in the gap between the comprehensive services addressing acute problems provided by EDs and the ongoing care provided by physicians in traditional office settings. These arguments include reduction of ED utilization for minor complaints with its attendant costs, reduction of ED overcrowding, reduction of waiting time for outpatient physician ap- pointments, and patient convenience. To reach these goals, four models have been developed to date. These include 1) the urgent care center; 2) the free standing emergency center; 3) the retail or convenience clinic; and 4) the walk in clinic. We will first outline the devel- opment of each model and then compare and contrast how each model attempts to meet these goals. It should be noted that the health care systems in which these models function vary from country to country.