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Are increases in emergency use and hospitalisation always a bad thing? Reflections on unintended consequences and apparent backfires
  1. Kaveh G Shojania
  1. Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
  1. Correspondence to Dr Kaveh G Shojania, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada; kaveh.shojania{at}

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Verschlimmbessern: German word meaning to make something worse in an effort to improve it

In this issue of BMJ Quality & Safety, Snooks et al 1 report a stepped-wedge trial involving 32 general practices in Wales. A web-based software program presented clinicians with estimates of patients’ risk of future emergency attendance on the basis of clinical characteristics, past health services use and socioeconomic factors. Clinicians could then develop management plans which would avoid acute deteriorations necessitating emergency department attendance. Surprisingly, the intervention caused a small but statistically significant increase in hospital admissions and use of other National Health Service services.

The authors deserve congratulations here because they undertook this evaluation precisely because policies intended to improve care or reduce costs often presume the effectiveness of a certain approach when little evidence exists to support it. Targeting high-cost users of healthcare is a widely recommend approach which is harder to execute than generally recognised.2 Identifying hospitalised patients at high risk for readmission also represents a topic where predicting risk comes easily but acting effectively does not.3 But, Snooks and colleagues have shown that not only is it hard to achieve an ambitious goal, sometimes an intervention which ought to work makes things worse.

That said, increases in the use of emergency services do not imply worse quality of care. Patients who made unplanned visits to the hospital may well have had acute issues not easily dealt with in an outpatient setting. Before returning to that question, we will briefly review unintended consequences in general, followed by a focus on the subset of such situations where a change produces the opposite of its intended goal.

Unintended consequences outside healthcare

Sociologist Robert Merton famously drew attention to the problem of unexpected, undesirable effects with his classic essay, ‘The Unanticipated Consequences of Purposive Social Action’. …

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