Use of unscheduled and urgent care in long term conditions

Use of urgent or unscheduled services is high. 16% of the general population access unscheduled care over any 4 week period and this proportion has remained stable over the last 5 years. This percentage is expected to be higher in Greece, since Accident and Emergency Departments (AED) in Greece frequently offer also primary care services. This project concerns people who have long term conditions and use unscheduled or urgent care frequently. The illnesses we will study (diabetes, chronic obstructive pulmonary disease [COPD] and rheumatologic disorders) are in the leading 15 discharge diagnoses of emergency departments and are associated with an emergency hospital admission during the subsequent 6 months. 

Psychological morbidity in long term conditions

A quarter of all patients with long term conditions have co-existing anxiety and depression which are associated with increased health service utilisation, poorer health outcomes and frequent use of accident and emergency department. Our previous research showed that the prevalence of Major Depression Disorder in Greek patients with rheumatologic disorders is estimated at 25.4%.

Psychological morbidity and impaired health

Patients who use unscheduled care often have severe physical illness as well as associated psychological problems so they have a range of unmet needs. In diabetes, depression is associated with more diabetes-related complications, impaired physical and mental health status and more emergency department visits. We have previously found that several psychological parameters are associated with delayed engagement to treatment in diabetes and that somatization is strongly independently associated with more severe self-reported dyspnoea in COPD. A multimodal intervention is required to meet the patients’ unmet needs if unscheduled care is to be reduced.

Scheduled and unscheduled care are highly correlated and studies of colleagues participating in our research team have shown that frequent scheduled care is associated with marked worry about the illness, fears that treatment will be ineffective and impaired coping. Qualitative studies have demonstrated overwhelming anxiety at times of crisis leading to use of unscheduled care.    

Reduction of Unscheduled Care

Reduction of the use of unscheduled care could relief the burden of A&E departments. Given the mixed and complex role that A&E departments hold in the Greek health-care environment, public policy is to provide services that are more appropriate for users’ and carers’ requirements.

Improving Quality of Care

The US Preventive Services Task Force has recently recommended that there is evidence for the efficacy of integrated care for depression in medical illness, when screening is coupled with system changes that help ensure adequate treatment and follow-up for depression. Furthermore, the following documents highlight the need to detect and treat psychosocial problems in physical disease: NICE Clinical Guideline 15 Type I Diabetes; NICE Clinical Guideline 12 COPD; DOH Report on Psychological Therapies 2004; NICE guidelines on “treatment of depression in people with chronic physical health problems” 2008.

Darzi Review: The Darzi review recommends that clinicians involved in acute care should be trained to recognise and manage acute psychological distress and there should be greater access to mental health support for patients seeking urgent care.