Developing effective strategies to reduce unscheduled care in chronic disease:  Validation of a ‘red flag’ system that identifies patients who are at risk of becoming frequent users of unscheduled care


Background and Rationale

This study  is  a  work  package  contributing  to  a  five-year  research  programme  funded  by  the National Institute for Health Research programme grant for applied research.

Use of urgent or unscheduled services is high in the UK and is common in people with long-term conditions. Those diagnosed with long-term conditions are more frequent users of the health care system than those without diagnosed long-term condition. In the UK, reduction of the use of unscheduled care in the NHS is a Department of Health priority. A number of recent health policy initiatives aim to provide the same or better services through optimal use of resources.  Understanding how people access urgent and emergency care will help commissioners and providers shape services that are more responsive and appropriate for users’ and carers’ requirements. People with long-term conditions often have associated psychological and mental health problems such as anxiety and depression. Qualitative studies have demonstrated overwhelming anxiety at times of crisis, worry about the illness, and impaired coping lead to use of scheduled and unscheduled care.  The outcome of medical illnesses is adversely affected by psychological morbidity. A number of studies had also shown that  depression  is  associated  with  increase  health  care  utilisation,  medical  costs,  disability  and  health outcomes and frequent use of accident and emergency department. A multimodal intervention including psychological interventions is required if urgent and unscheduled care is to be reduced.


This research programme aims to understand the need for urgent or unscheduled healthcare and assess whether the need may be reduced  if  more  comprehensive  routine  care  is  developed. The  overall  objective  of  this  research programme is to develop effective psychosocial strategies to reduce the need for frequent unscheduled care in patients with four long term conditions; these are: diabetes, here coronary heart disease, treat asthma and chronic  obstructive  pulmonary  disease.    The  research  programme  tests  whether  appropriate  help  with emotional  difficulties  leads  to  less  demand  for  unscheduled  care. One  of  the  specific  objectives of  the research programme is to develop a ‘red flag’ system that will identify patients with long term conditions who are at risk of becoming frequent users of unscheduled care .


The objective is  to  test  the validity  of  a  ‘red  flag’  system  which  will be  developed  by  the  NIHR funded research programme for identifying patients with long term conditions who are at risk of becoming frequent users of unscheduled care. The present study will:

  • Extract,  de-identify  and  link  demographic  and  relevant  clinical  data  across  primary  and  secondary healthcare services for analysis in two study sites in England
  • Model  predictors  of  utilisation  of  unscheduled  care  using  de-identified  demographic  and  relevant clinical data across primary and secondary healthcare services
  • Compare the predictors of utilisation of unscheduled care with the ‘red flags’ to identify patients with LTC  who  are  at  risk  of  becoming  frequent  users  of  unscheduled  care  identified  in  the  research programme

The study design is a cohort study to model predictors of utilisation of unscheduled care using routinely collected clinical data in two localities.

Routinely collected clinical and activity data across primary and secondary healthcare services in two study sites will be extracted, de-identify and link to model predictors of utilisation of healthcare services including unscheduled  care  in  the  five  year  period.    The  study  will also explore  other  sub-groups  of  unscheduled admissions.

Two potential areas are:

(1) Ambulatory care sensitive (ACS) conditions;

(2) People admitted for short periods (zero to three days) where no procedure is carried out.

Subjects and Setting: The study sample will consist of adult list populations of participating GP practices in two study sites: likely to be Doncaster, NW London or Birmingham.

Outcome measures: The  primary  outcome  measures  are  utilisation  of  secondary  care  services,  and included  unscheduled  care: inpatient  episodes,  out-patient  appointments,  and  attendances  of  accidence  and  emergency  (A&E) departments in the five-year period between 01/04/2007 and 31/03/2012.

Data sources for the study:

  • GP Practice data from participating GP practices in the 2 study sites
  • Secondary care data for participating GP practices

MIQUEST  (Morbidity  Information  QUery  and  Export  SynTax),  a  Department  of  Health  approved  data interrogation software, will be used to extract information from GP computer systems.  Secondary care data will be accessed via the national SUS data.  Appropriate demographic, clinical and activity information recorded in GP practice information systems and secondary care data recorded in the national SUS data will be de-identified and linked for analysis.

Specific approval from the National Information Governance Board for Section 251 of NHS Act 2006 and Health Service (Control of Patient Information) Regulations 2002 exemption to support the use of patient identifiable information for the purpose of de-identification will therefore be sought