Why patients self-refer to the emergency service for nonurgency?: A mix-method survey from a family medicine perspective

Abstract

The definition of “nonurgent emergency service visits” is visits to conditions for medical conditions that require attention but are not life-threatening immediately or severe enough to require urgent intervention. This study aims to investigate the reasons why patients choose to self-refer to the emergency service (ES) instead of their primary care health center for nonurgent complaints. The study was carried out in a tertiary hospital. The survey consisted of 2 parts with sociodemographic questions, knowledge of their family physician, and the reason why it has been applied to the ES with multiple choice answers. Of the 325 patients, the mean age was 34.5 years and 54.2% were women. Also, 26 of the patients were reported as “urgent” by the doctor. The main reasons underlying self-referred patients were classified into 4 themes: “urgency” (13.8%), advantages of ES (12.9%); disadvantages of primary care (25.1%), and other (45.9%). The most common reason patients self-refer to the ES was their belief in “being urgent” (61%). In this study, 26.8%, (n = 84) of the patients are not happy with their family physicians, while only 13.2% (N = 43) prioritize the ES advantages.

1. Introduction

Nonurgent emergency service (ES) visits refer to instances where medical attention is needed for conditions that, while requiring prompt care, do not pose an immediate threat to life or require urgent intervention due to their severity.^[1] When individuals choose to visit an ES for nonurgent conditions instead of seeking care at alternative sites, such as a physician’s office or retail clinic, this can have several negative consequences. This negatively affects patient care quality and satisfaction with patients and ES personnel.^[2] Furthermore, it causes excessive healthcare spending, unnecessary tests and treatment, and missed opportunities to foster long-term relationships with primary care physicians, who are key members of primary healthcare.^[1]

In Turkey, ES operate according to the Anglo-American model. In this model, ES provide the highest level of emergency, and specialists are involved in providing care. According to regulations issued by the Turkish Ministry of Health in 2009, a 3-level triage system was implemented for ES.^[3] In Turkey’s ES system, patients are classified as green, yellow, or red starting with the lowest level of urgency. The green category includes patients in the low-risk group, which means “nonemergency” and that can be examined in outpatient clinics like primary care centers.^[4]

ES provide essential initial medical care designed to address a variety of acute and urgent illnesses and injuries. They were not designed to deal with nonurgent primary care issues.^[5] The attendance of nonurgent patients in ES has become a major global public health issue.^[2]

ES worldwide face a growing burden as patient attendance continues to increase. In the United Kingdom and the United States, more than 139 million and 23.8 million patients sought care in hospital emergency departments in 2017, respectively, while Australia witnessed an attendance of 8 million. This trend is driven by the increasing number of lower-urgency cases, which make up approximately one-third of ES visits worldwide.^[6] In France, inappropriate visits to ES have been reported to account for 20% to 40% of all visits.^[7] In a recent study in Saudi Arabia; 62% of the applications of ES applications were found to be nonurgent.^[8] Similarly, in Turkey, it is estimated that of the 160 million self-referred patients applied to emergency departments annually, only 20% are classified as genuine emergency cases.^[9] These figures highlight the significant proportion of nonurgent cases that contribute to the burden faced by ES in all countries. Another international review highlighted the issues of reliability and reproducibility in the methods and criteria used to classify visits to ES as nonurgent cases. This indicates that there is no straightforward method for accurately determining the actual burden on nonurgent patients in the ES.^[10]

In the Turkish national health system, patients are required to register with a regular family physician (FP), and family doctors do not control access to secondary care, meaning that they are not “gatekeepers.”^[11] Additionally, the primary healthcare system is free to access primary healthcare centers or state hospitals’ policlinics and ES for citizens with national social security insurance. In Turkey, during office hours (08:00–17:00), patients can choose whether to consult their FP, policlinics, or the hospital.^[12]

The average annual contact with primary healthcare facilities in Turkey was 3.2 per person. However, the number of applications from secondary and tertiary health institutions is 6.3.^[13] In Finland, a study on improving the recording of diagnoses in ES was designed equally well in the emergency department and office hours practices.^[14] Studies have been conducted to determine the reasons for nonurgency visits of patients and have found that it is multidimensional.^[2,15,16] This study aimed to investigate why patients chose to self-refer to the emergency department instead of their primary care health center for nonurgent complaints. Our goal was to determine the specific characteristics of the adults themselves, their complaints, their FPs, and the relationship between the patients and their FPs that influences this decision-making process.

2. Materials and methods

This was a cross-sectional descriptive study with a mixed-research design. As the subject is multidimensional, a systematic review of 39% of these studies was either qualitative or mixed.^[17] The study was conducted between May and June 2018 at Mengücek Gazi University and Training Hospital, a tertiary hospital in the city center. The hospital is the only tertiary hospital with a capacity of 235 beds in Erzincan, a rural city in eastern Turkey with a population of approximately 260,000.^[18,19] At the same hospital, ES were ruined using a 3-level classification system.^[4]

The data were collected from adult patients who applied to the emergency department during office hours (08:00–17:00) between Monday and Friday, when other policlinics and primary health care centers are eligible to apply for nonurgent health problems. Self-referred patients applied to the ES directed to the green area, which means that they are “nonurgent” by a triage nurse, who participated in the study. All nurses performing the classification are registered nurses with a minimum of 6 months of experience in ES patient care. The patient selection process for the study involved the convenience sampling method, in which triage nurses selected patients according to convenience or availability.^[20] After an oral explanation, the patients who agreed to participate in the study provided written consent. Each patient subsequently completed the survey. The patients were instructed to submit the completed forms to the triage unit after treatment completion. Including criteria were: patients over 18 years old, directed to the “green area”; Turkish speaking, acceptance of participation. Patients who arrived at the emergency room with an ambulance, patients who moved to the “yellow zone” after the emergency physician’s examination, and patients who did not answer all the survey questions properly were excluded from the study. The survey consisted of 2 parts with sociodemographic questions, the knowledge of the FP, and the reason for applying it to the ES with multiple-choice answers. The second part of the survey contained an open question about the underlying factors that did not apply to the FP’s office. The survey was designed by researchers who scanned the literature. The survey was analyzed using the SPSS statistical program. The responses to the open-ended questions were divided into themes by 2 independent researchers. This study was approved by the Erzincan Binali Yildirim University Clinical Research Ethics Committee (Ethics Committee Date: May 30, 2019; No.06/02).

Statistical analyses were performed using IBM SPSS Version 28.0 (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp.). Qualitative data are presented as frequencies and related percentage values, whereas quantitative data are expressed as medians (minimum: maximum). Categorical variables were compared between groups using Pearson Chi-square, Fisher exact, and Fisher–Freeman–Halton tests. At the end of the study, patient complaints and justifications for preferring ES were grouped and evaluated using the grounded theory. Statistical significance was set at α = 0.05.

3. Results

Of the 370 applicants for green areas, 19 were excluded from the study because they had not completed the survey correctly. Among these applicants, 26 were evaluated as genuine emergency cases. The most common reason for applying to the genuine emergency group was trauma, followed by allergies and assault. The 26 individuals who were evaluated as genuine emergencies were also excluded from the study, as mentioned in the literature.^[14] Consequently, 325 patients were included in this study (Fig. 1).

Figure 1.

Patient inclusion flow diagram. ES emergency service.

The mean age of the 325 patients was 34.5 ± 16.42 years (range, 18–90 years). Of them, 54.2% (n = 176) were women. After emergency doctor examination of 351 patients 6.8% (n = 26) were reported as “urgent.” However, 11.7% (n = 41) of the patients expressed themselves as “urgent.” It shows that 6 out of every 10 self-referred patients who consider themselves urgent are nonurgent.

The knowledge of FPs was 78.5% (n = 255). There was no significant difference between FP knowledge and self-reference as “urgent” (P = .161).

Only 23.4% (n = 76) of the patients had chronic diseases. There was a statistically significant difference between having at least 1 chronic disease and the knowledge of an FP (P = .009). Furthermore, there was a significant difference in the reference of people with chronic diseases to ES as “emergency” (P < .05).

In this study, the open question was analyzed using grounded theory. The main reasons underlying self-referred patients who are “nonurgent” were categorized into 4 themes: The feeling of being “urgent”; the efficiency of ES, the disadvantages of FP and other reasons not related much to the issue (Table 1).

Table 1.

Themes of reasons underlying the nonurgent self-referred patients who apply to the emergency services during office hours.

Reasons underlying the nonurgent self-referred patients who apply to the emergency services during office hours
Themes	Theme 1 The feeling of being “Urgent”	Theme 2 Efficacy of ES (N = 43)	Theme 3 Disadvantages of FP	Theme 4 Other
Subthemes	Subtheme 1.1 Thinking it is an emergency “I have a serious health problem”	Subtheme 2.1 Practical (n = 7)	Subtheme 3.1 Unreachable “FP is out of the office during the day”	Subtheme 4.1 Need for invasive treatment “I think I need intravenous treatment”
Quitos	Subtheme 1.2 Feeling excessive pain “I can’t wait, I am in pain”	Subtheme 2.2 Easy to access (n = 20)	Subtheme 3.2 Dissatisfaction of FP “FP does not examine properly” “I think FP is useless”	Subtheme 4.2 On duty in military service “I am a soldier”
	Subtheme 1.3 Anxiety of health “I am worried about my health status”	Subtheme 2.3 Full equipmented (n = 4)	Subtheme 3.3 I don’t know the FP	Subtheme 4.3 Attitude “I work in this hospital” “I came to visit a patient”
		Subtheme 2.4 Rapid consultation (n = 6) “I don’t want to wait in line in policlinics”
		Subtheme 2.5 Better than FP (n = 6)

ES = emergency service, FP = family physician.

It is estimated that 25.8% (n = 84) of the patients were unhappy with their FP while only 13.2% (n = 43) prioritized the advantages of ES. Quitos: “I dislike my FP”; P169 “My FP is irrelevant”; P164, P165, P174.

4. Discussion

Several individuals have characterized the utilization of ES resources by self-referred patients with nonurgent conditions, conditions that could have been addressed through primary care, pharmacies, or telephonic advice, as “inappropriate.” These patients resort to ES for immediate consultation, diagnostic tests, and medication provision to alleviate their nonurgent symptoms. However, the classification of certain ES visits as “inappropriate” prompts us to ponder what criteria should determine appropriateness and the implicit assumptions informing such judgments.^[16] On the other hand, some studies have shown that 3% to 5% of patients classified as “nonurgent” require immediate hospitalization after further evaluation at ES.^[1] A total of 380 patients who participated in the study volunteered; 6.8% (n = 26) of them were determined as “urgent” after the physical examination of the emergency physician and were excluded from the study.

In a systemic review, the findings were inconsistent among 10 articles that examined gender.^[1,21] Similarly, our study did not find a significant difference between FP knowledge and preference for ES according to sex.

In other studies, the average age of self-referred patients was <40 years.^[15,21,22] Older adults tend to have more urgent medical visits than younger adults.^[1] The mean patient age was 34 years. These results suggest that nonurgent patients are predominantly middle-aged individuals without chronic diseases.^[8] Sometimes, patients develop the habit of visiting hospitals at a young age and may not have accepted the idea of initially consulting a primary care physician.^[10] See the quote “I always apply ES” P323.

Nonemergent patients tend to visit ES because of illness rather than injury.^[15] In this study, only 2% of the patients who did not respond to ES experienced trauma. Almost one-third (32.1%) of the participants indicated that they had attempted to reach their FP before coming to the ES.^[22] In our study, it is 8.3% (n = 27).

The reasons that nonurgent patients did not seek primary care were accessibility (32%), perception of need (22%), referral/follow-up to the ES (20%), familiarity with the ES (11%), trust in the ES (7%), and no reason (7%).^[23] A similar finding was found in this study; self-reported patients were asked about their preferences: feeling of urgency (13.8%), advantages of ES (12.9%); disadvantages of FPs (25.1%), and other reasons (45.9%). The proximity of ES in terms of transportation is the primary reason for their application.^[3,24] It is estimated that the highest-rated advantage of ES is that it is “easy to access” in our study. Patients frequently reported other motivational factors such as proximity to the hospital compared to the practice of their primary care physician or the belief that they would receive quicker assistance in a hospital setting.^[25]

In another study in Turkey, it was estimated that 12.4% of patients were admitted to the hospital for another reason, which was the reason they applied to the ES.^[8] In our study, only 2.1% of the patients were the same. The motivating factors for consulting an ES rather than primary healthcare appear to be personal convenience, accessibility to emergency facilities, and geographic proximity in France.^[26] In Norway, this problem has been highlighted in appointment problems.^[27] In this study, it is 6.46%. According to this study, even patients who know their FPs have the opportunity to schedule appointments and prefer ES.

Among all visits, 68% were nonurgent; within this category, 51.6% were still perceived as urgent.^[28] In this study, 14.1% of the patients thought their health status was urgent. The most common reason that patients came to the emergency room was their belief that their problems were serious (61%).^[10] In Belgium, more than a third of self-referring patients who attended the ES during daytime hours reported doing so because they perceived their health problems as urgent and anticipated the need for advanced diagnostic tests.^[29]

The expectation was to require radiological or laboratory investigations (372 patients, 23.8%) in a Dutch study.^[30] The reason for this study was access to intravenous treatment, which can also be performed in primary health care centers.

Another study designed for adolescents aged 12 to 21 years showed that the first reason for applying for ES was the perception of the participant of the disease, which required immediate care in the range of 34%.^[24] In our study, 77 patients aged 18 to 21 applied with ES, and 23.6% of them thought that their disease needed to be urgently cured.

Having an FP has been associated with the reduced use of ES at any age of life.^[6] In our study, 78.5% of the patients knew their FP and still preferred the emergency department during office hours. Three key areas that influenced a patient’s decision-making process in selecting where to consult emerged: the quality of their relationship with their primary care physicians, the perceived nature of the complaint, and the expected waiting time before receiving care.^[31] In this study, 25.8% (n = 84) of the patients were unhappy with their FPs while only 13.2% (n = 43) prioritized the advantages of ES.

There are different reasons for nonurgent patients to visit ES in Saudi hospitals, including lack of services and healthcare providers in primary care, availability of services in ES, and fast access.^[32] The most common reason for ES consultation in Japan is the desire to cure quickly.^[16] In this study, out-of-office FP (via home visits, etc), dissatisfaction with FP consultation, and physical distance compared to emergency departments play a role in seeking health care.

The limitations of the study are that it is a single-center study, and only seasonal data were collected.

4.1. Strengths of the study

Evaluation from the perspective of family medicine and in-depth examination of causes with open questions, along with survey questions—exclusion of real emergencies from work.

5. Conclusion

Empowering the relationship between the patient and the FP plays an important role. Patients with chronic diseases are more likely to know their general practitioners. In contrast, the more the patients had chronic diseases, the more they tended to self-refer to ES. Chronic disease management by FPs or patients may be a solution to this multidimensional problem.

Acknowledgments

The authors thank Prof. Dr. Güven Özkaya for the statistical support.

Author contributions

Conceptualization: Canan Tuz.

Data curation: Canan Tuz.

Formal analysis: Canan Tuz.

Funding acquisition: Canan Tuz.

Investigation: Canan Tuz.

Methodology: Canan Tuz.

Project administration: Canan Tuz.

Resources: Canan Tuz.

Software: Canan Tuz.

Writing—original draft: Canan Tuz.

Supervision: Alis Özçakir.

Validation: Alis Özçakir.

Visualization: Alis Özçakir.

Writing—review & editing: Alis Özçakir.