title: A qualitative study of patient choices in using emergency health care for long-term conditions: the importance of candidacy and recursivity.
abstract: OBJECTIVE
  We aimed to explore how patients with long-term conditions choose between available healthcare options during a health crisis.
  
  
  METHODS
  Patients in North-West England with one or more of four long-term conditions were invited to take part in a questionnaire cohort study of healthcare use. Semi-structured interviews were conducted with a sub-sample of fifty consenting patients. Data were analysed qualitatively, using a framework approach.
  
  
  RESULTS
  Patients described using emergency care only in response to perceived urgent need. Their judgements about urgency of need, and their choices about what services to use were guided by previous experiences of care, particularly how accessible services were and the perceived expertise of practitioners.
  
  
  CONCLUSIONS
  Recursivity and candidacy provide a framework for understanding patient decision-making around emergency care use. Patients were knowledgeable and discriminating users of services, drawing on experiential knowledge of healthcare to choose between services. Their sense of 'candidacy' for specific emergency care services, was recursively shaped by previous experiences.
  
  
  CONCLUSIONS
  Strategies that emphasise the need to educate patients about healthcare services use alone are unlikely to change care-seeking behaviour. Practitioners need to modify care experiences that recursively shape patients' judgements of candidacy and their perceptions of accessible expertise in alternative services.
authors.affiliation: Nuffield Department of Population Health, University of Oxford, Oxford, UK. Electronic address: cheryl.hunter@dph.ox.ac.uk.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Hunter
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
authors.forename: Susanne
authors.initials: S
authors.lastname: Langer
authors.forename: Alexandra
authors.initials: A
authors.lastname: Stenhoff
authors.forename: Jessica
authors.initials: J
authors.lastname: Drinkwater
authors.forename: Elspeth
authors.initials: E
authors.lastname: Guthrie
authors.forename: Peter
authors.initials: P
authors.lastname: Salmon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001249:Asthma / Q000628:therapy; D002755:Choice Behavior; D003327:Coronary Disease / Q000628:therapy; D003920:Diabetes Mellitus / Q000628:therapy; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D004739:England; D005260:Female; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D007407:Interviews as Topic; D007600:Judgment; D008297:Male; D008875:Middle Aged; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy; D036301:Qualitative Research; D011795:Surveys and Questionnaires
keywords: Asthma; Candidacy; Chronic obstructive pulmonary disease; Coronary heart disease; Diabetes; Emergency healthcare; Healthcare utilisation; Longterm conditions; Patient decision-making; Patient experiences; Primary health care; Qualitative research; Recursivity; Theory; Unscheduled care