A qualitative study of patient choices in using emergency health care for long-term conditions: The importance of candidacy and recursivity

Hunter, Cheryl; Chew‐Graham, Carolyn; Langer, Susanne; Stenhoff, Alexandra; Drinkwater, Jessica; Guthrie, Elspeth; Salmon, Peter

doi:10.1016/j.pec.2013.06.001

Cited by 65 publications

(102 citation statements)

References 22 publications

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“…For instance, other researchers have extended Dixon-Woods' concept and adopted the Candidacy lens when exploring healthcare access across a range of social groups (Hunter et al, 2013;Klassen et al, 2008;Koehn, 2009;Kovandzic et al, 2011;Mackenzie et al, 2013;Purcell et al, 2014) and propose additional dimensions (race, gender, symptom-type), often alongside social disadvantage, that similarly impinge on the Candidacy process.…”

Section: Illness Identity As An Important Component Of Candidacy: Conmentioning

confidence: 99%

Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

Macdonald

Blane

Browne

et al. 2016

Social Science & Medicine

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How and when we use health services or healthcare provision has dominated exploration of and debates around healthcare access. Levels of utilisation are assumed as a proxy for access. Yet, focusing on utilisation conceals an important aspect of the access conundrum: the relationships that patients and potential patients have with the healthcare system and the professionals within those systems. Candidacy has been proposed as an antidote to traditional utilisation models. The Candidacy construct offers the ability to include patient-professional aspects alongside utilisation and thus promotes a deeper understanding of access. Originally applied to healthcare access for vulnerable populations, additional socio-demographic factors, including age and ethnicity, have also been shown to influence the Candidacy process. Here we propose a further extension of the Candidacy construct and illustrate the importance of illness identities when accessing healthcare.Drawing on a secondary data analysis of three data sets of qualitative interviews from colorectal cancer and heart failure patients we found that though similar access issues are apparent prediagnosis, diagnosis marks a critical juncture in the experience of access. Cancer patients describe a 2 person-centred responsive healthcare system where their patienthood requires only modest assertion. Cancer speaks for itself. In marked contrast heart failure patients, describe struggling within a seemingly impermeable system to understand their illness, its implications and their own legitimacy as patients. Our work highlights the pressing need for healthcare professionals, systems and policies to promote a person centred approach, which is responsive and timely, regardless of illness category. To achieve this, attitudes regarding the importance or priority afforded to different categories of illness need to be tackled as they directly influence ideas of Candidacy and consequently access and experiences of care.

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Section: Illness Identity As An Important Component Of Candidacy: Conmentioning

confidence: 99%

Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

Macdonald

Blane

Browne

et al. 2016

Social Science & Medicine

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“…4 Research focusing on people with long-term conditions suggests that they understand which services are available and choose those that suit them most. 66 They see newer services such as walk-in centres as not offering the technological input of the ED or the established relationship of general practice. The permeability or ease of access of a service affects their choice, with EDs viewed as more permeable than general practice.…”

mentioning

confidence: 99%

“…The permeability or ease of access of a service affects their choice, with EDs viewed as more permeable than general practice. 66 For people with long-term conditions, …”

mentioning

confidence: 99%

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

O’Cathain

Knowles

Turner

et al. 2014

Health Services and Delivery Research

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BackgroundRecent increases in emergency admission rates have caused concern. Some emergency admissions may be avoidable if services in the emergency and urgent care system are available and accessible. A set of 14 conditions, likely to be rich in avoidable emergency admissions, was identified by expert consensus.ObjectiveWe aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.MethodsThe design was a sequential mixed-methods study in three phases. In phase 1 we calculated an age- and sex-adjusted avoidable admission rate for 2008–11. We located routine data on characteristics of emergency and urgent care systems and used linear regression to explain variation in avoidable admissions rates in 150 systems. In phase 2 we undertook in-depth case studies in six systems to identify further factors. A key part of these case studies was interviews with commissioners, service providers and patient representatives, totalling 82 interviews. In phase 3 we returned to the linear regression to test further factors identified in the case studies.ResultsThe 14 conditions accounted for 3,273,395 admissions in 2008–11 (22% of all emergency admissions). The mean age- and sex-adjusted admission rate was 2258 per year per 100,000 population, with a 3.4-fold variation between systems (1268–4359). Characteristics of the population explained the majority of variation: deprivation explained 72% of variation, with urban/rural status explaining 3% more. Systems serving populations with high levels of deprivation and in urban areas had high rates of potentially avoidable admissions. Interviewees described the complexity of deprivation, representing high levels of morbidity, low awareness of alternative services to emergency departments and high expressed need for immediate access to urgent care. Factors related to emergency departments (EDs), hospitals, emergency ambulance services and general practice explained a further 10% of variation in avoidable admissions. Systems with high, potentially avoidable, admission rates had high rates of acute beds (suggesting supply-induced demand), high rates of attendance at EDs (which have been associated with poor perceived access to general practice), high rates of conversion from ED attendances to admissions, and low rates of non-transport to emergency departments by emergency ambulances. The six case studies revealed further possible explanations of variation: there was variation in how hospitals coded admissions; some systems focused proactively on admission avoidance whereas others were more interested in hospital discharge, for example use of multidisciplinary teams based at acute trusts; there were different levels of integration between different services such as health and social care, and acute and community trusts; and some systems faced more challenging problems around geographical boundaries operating for different services in the system. Interviewees often described admission as the easy or safe option.ConclusionsDeprivation explained most of the variation in avoidable admission rates. Research is needed to understand the complex relationship between deprivation and avoidable admission, and to develop interventions tailored to avoid admissions from deprived communities. Standardisation of coding of admissions would reduce variation.FundingThe National Institute for Health Research Health Service and Research Delivery programme.

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“…A newly published study from Great Britain, another country with universal coverage, found many of the same factors driving ED use as did Lawson et al 7 Interviews with 50 individuals, mostly white, of whom 34 were retired, found that prior care experiences and perceived severity of illness were major drivers of ED use. One 62 year-old man with asthma noted that ED staff … know you're having any sort of attack or symptoms related to your asthma, they, they are good.…”

mentioning

confidence: 73%

“…Where in hospital they've got everything there, they've got the ventilators, the drips, they've got everything, they can resuscitate you, if need be (…) I feel safe going in a hospital. 7 It is time to reframe the ED visit, too often viewed as a failure of health care, as the opposite. The modern U.S. ED represents the triumph of a half-century's worth of effort to provide Americans with accessible, affordable, technically and clinically competent, compassionate care at all times.…”

mentioning

confidence: 99%

ED Care: Available, Competent, Affordable

Bernstein

2013

Academic Emergency Medicine

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A qualitative study of patient choices in using emergency health care for long-term conditions: The importance of candidacy and recursivity

Cited by 65 publications

References 22 publications

Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

ED Care: Available, Competent, Affordable

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