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      ‘Clinically unnecessary’ use of emergency and urgent care: A realist review of patients' decision making

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          Abstract

          Background

          Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

          Objective

          To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

          Design

          Realist review.

          Methods

          Papers 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.

          Results

          Six 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.

          Conclusions

          Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

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          Most cited references85

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          Poverty impedes cognitive function.

          The poor often behave in less capable ways, which can further perpetuate poverty. We hypothesize that poverty directly impedes cognitive function and present two studies that test this hypothesis. First, we experimentally induced thoughts about finances and found that this reduces cognitive performance among poor but not in well-off participants. Second, we examined the cognitive function of farmers over the planting cycle. We found that the same farmer shows diminished cognitive performance before harvest, when poor, as compared with after harvest, when rich. This cannot be explained by differences in time available, nutrition, or work effort. Nor can it be explained with stress: Although farmers do show more stress before harvest, that does not account for diminished cognitive performance. Instead, it appears that poverty itself reduces cognitive capacity. We suggest that this is because poverty-related concerns consume mental resources, leaving less for other tasks. These data provide a previously unexamined perspective and help explain a spectrum of behaviors among the poor. We discuss some implications for poverty policy.
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            Some consequences of having too little.

            Poor individuals often engage in behaviors, such as excessive borrowing, that reinforce the conditions of poverty. Some explanations for these behaviors focus on personality traits of the poor. Others emphasize environmental factors such as housing or financial access. We instead consider how certain behaviors stem simply from having less. We suggest that scarcity changes how people allocate attention: It leads them to engage more deeply in some problems while neglecting others. Across several experiments, we show that scarcity leads to attentional shifts that can help to explain behaviors such as overborrowing. We discuss how this mechanism might also explain other puzzles of poverty.
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              Uncertainty in Illness

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                Author and article information

                Contributors
                Role: Professor of Health Services Researcha.ocathain@sheffield.ac.uk
                Role: Research Associate
                Role: Research Associate
                Role: Research Fellow
                Journal
                Health Expect
                Health Expect
                10.1111/(ISSN)1369-7625
                HEX
                Health Expectations : An International Journal of Public Participation in Health Care and Health Policy
                John Wiley and Sons Inc. (Hoboken )
                1369-6513
                1369-7625
                29 October 2019
                February 2020
                : 23
                : 1 ( doiID: 10.1111/hex.v23.1 )
                : 19-40
                Affiliations
                [ 1 ] School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
                Author notes
                [*] [* ] Correspondence

                Alicia O'Cathain, School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.

                Email: a.ocathain@ 123456sheffield.ac.uk

                Author information
                https://orcid.org/0000-0003-4033-506X
                https://orcid.org/0000-0003-4609-3911
                https://orcid.org/0000-0002-6889-6195
                https://orcid.org/0000-0002-0599-4222
                Article
                HEX12995
                10.1111/hex.12995
                6978874
                31663219
                cab102ca-5d2f-4fdf-8a77-a05e61aa99f9
                © 2019 The Authors Health Expectations published by John Wiley & Sons Ltd

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 27 June 2019
                : 08 October 2019
                : 09 October 2019
                Page count
                Figures: 2, Tables: 2, Pages: 22, Words: 16276
                Funding
                Funded by: Health Services and Delivery Research Programme , open-funder-registry 10.13039/501100002001;
                Award ID: 15/136/12
                Categories
                Review Article
                Review Articles
                Custom metadata
                2.0
                February 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.5 mode:remove_FC converted:24.01.2020

                Health & Social care
                emergency medicine,heath care seeking behaviour,patients,urgent care
                Health & Social care
                emergency medicine, heath care seeking behaviour, patients, urgent care

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