Asthma 3+ Visit Plan: a qualitative evaluation

Unscheduled care (UC) refers to non‐routine face‐to‐face care, such as accident and emergency care, out‐of‐hours care, or walk‐in centres. Current health service policy aims to reduce its use. Unscheduled care is common in people with long‐term conditions such as diabetes, asthma, chronic obstructive pulmonary disease and coronary heart disease. By reviewing qualitative research literature, we aimed to understand the breadth of psychosocial and other influences on UC use in people with long‐term conditions. Few qualitative papers specifically address UC in patients in these disease groups. Therefore, our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to healthcare use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011, we identified 42 papers, published since 1984, describing relevant original research and took a meta‐ethnographic approach in reviewing them. The review was conducted between Spring 2009 and April 2011, with a further search in December 2011. Most papers reported on asthma (n = 13) or on multiple or unspecified conditions (n = 12). The most common methods reported were interviews (n = 33) and focus groups (n = 13), and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the ‘problem’ of UC, and health‐care, use in general, decontextualised from the lives of the patients using it. Patients’ use of UC emerged as understandable, rational responses to pressing clinical need in situations in which patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.

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“…Forty‐two papers formed the final data set. Of this set, six papers (Douglass et al. 2002, 2004, 2005, Goeman et al.…”

Section: Methodsmentioning

confidence: 99%

Why do patients with long-term conditions use unscheduled care? A qualitative literature review

Langer

Chew‐Graham

Hunter

et al. 2012

Health Soc Care Community

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“…Finally, much of the qualitative asthma literature comes from Australia and the United Kingdom and therefore may not identify system-level reasons for ED use that are specific to the United States. [18][19][20][21][22][23][24][25][26] The objective of our study was to use interviews with asthma patients during ED visits to explore the range of reasons for asthma-related ED utilization.…”

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confidence: 99%

“No Other Choice”: Reasons for Emergency Department Utilization Among Urban Adults With Acute Asthma

Lawson

Carroll

Gonzalez

et al. 2014

Academic Emergency Medicine

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Objectives: Asthma is considered "ambulatory care-sensitive," yet emergency department (ED) visits remain common. Few studies have examined how ED asthma patients choose their sites of urgent care. The authors explored reasons for asthma-related ED use among adults.Methods: From May to September 2012, semistructured qualitative interviews were conducted with a convenience sample of patients visiting a high-volume urban ED for asthma. A piloted interview guide was used; it had open-ended questions derived from clinical experience and a focus group of asthmatic adults who frequently use the ED for care. Interviews were conducted until theme saturation was reached. Interview transcripts and field notes were entered into NVivo 10 and double-coded, using an iterative process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis.

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“…Forty-two papers were identified as eligible for inclusion in this review: Aroni et al, 189 Becker et al, 190 Cvetkovski et al, 191 Donald et al, 155 Douglass et al, [192][193][194] Goeman et al, 136,195 Griffiths et al, 196 Hyland et al, 197 Jones et al, 198 Tumiel-Berhalter and Zayas, 199 De Vito, 200 Elkington et al, 110 Hopley et al, 201 Shipman et al, 202 Wilson et al, 203 Balcou-Debussche and Debussche, 204 Brez et al, 205 Broom,206 de-Graft, 207 Heisler et al, 208 Johnson et al, 209 Lawton et al, 210 McDowell et al, 211 Perera et al, 212 Mead et al, 213 Paquet et al, 214 Schoenberg and Peters, 215 Cowie et al, 216 Forsyth et al, 217 Fried et al, 218 Gately et al,…”

Section: Resultsmentioning

confidence: 99%

“…In total, 14 studies were of patients with asthma, 136,155,[189][190][191][192][193][194][195][196][197][198][199]212 five were of patients with COPD, 110,[200][201][202][203][204] seven were of patients with diabetes, [205][206][207][208][209][210][211] three were of patients with CHD 213-215 and 11 were of patients with mixed/multiple LTCs. [216][217][218][219]221,222,[224][225][226][227][228] The majority of studies were from the USA (n = 11 190,199,200,208,213,215,217,218,222,224,…”

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confidence: 99%

“…[216][217][218][219]221,222,[224][225][226][227][228] The majority of studies were from the USA (n = 11 190,199,200,208,213,215,217,218,222,224,225 ), Australia (n = 12 136,155,189,[191][192][193][194][195]206,220,221,227 ) or the UK (n = 12 110,196,197,202,[209][210][211]216,219,223,226,228 ). The most frequently studied types of unscheduled care were attendance at the ED and/or EHA.…”

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confidence: 99%

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CHOICE: Choosing Health Options In Chronic Care Emergencies

Guthrie

Afzal

Blakeley

et al. 2017

Programme Grants Appl Res

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BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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Asthma 3+ Visit Plan: a qualitative evaluation

Abstract: Our findings support the Asthma 3+ Visit Plan as a discharge strategy for recurrent emergency attendees with asthma.

Cited by 9 publications

References 20 publications

Why do patients with long-term conditions use unscheduled care? A qualitative literature review

Why do patients with long-term conditions use unscheduled care? A qualitative literature review

“No Other Choice”: Reasons for Emergency Department Utilization Among Urban Adults With Acute Asthma

CHOICE: Choosing Health Options In Chronic Care Emergencies

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