Abstract
BackgroundDemand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.ObjectiveTo identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.DesignRealist review.MethodsPapers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.ResultsSix mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.ConclusionsRather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.
Highlights
Demand is abe ed c inica y unnecessary when patients do not need the eve s of c inica care or urgency provided by the service they contact
We identified our outcome of interest as the use of an emergency and urgent care service that was judged as c inica y unnecessary We undertook the review in two phases The first phase invo ved deve oping and refining a set of programme theories based on qua i tative research The second phase invo ved testing these programme theories using existing theories of hea th behaviour and identifying ev idence to support or refute them in re evant quantitative studies We registered the proposa with PROSPERO
The wider project team cha enged us to be c earer about the specific mechanisms driving the need for urgency and this ed to further discussion through which we FIGURE Summary of search se ection and extraction of artic es identified under ying mechanisms within the programme the ories Fina y we presented these under ying mechanisms and programme theories for discussion to the project advisory group where members had backgrounds in emergency department med icine paramedic practice hea th care commissioning research in emergency and urgent care po icy making and patient and pub ic invo vement October
Summary
Demand is abe ed c inica y unnecessary when patients do not need the eve s of c inica care or urgency provided by the service they contact.
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