Why do patients seek emergency care for problems that could be managed in primary care? A scoping review

Abstract

Background

Emergency care systems worldwide are increasingly facing capacity challenges. A significant number of people are using emergency care, including the use of emergency departments and ambulance services, for conditions that could be managed in primary care settings, potentially creating unnecessary strains on the already heavily burdened emergency care systems, leading to overcrowding, inefficient use of healthcare resources, and inadequate access to emergency care for those in need.

Objectives

This scoping review of the literature aimed to explore existing evidence considering the multifaceted factors contributing to patients’ decisions to seek emergency care for conditions manageable in primary care.

Methods

A comprehensive search of “PubMed”, “Embase”, “MEDLINE”, “CINAHL” and “the Cochrane Library” was conducted, including peer-reviewed articles published from Jan 1st 2004, until June 15th 2024. This review was conducted following the methodological framework presented by Arksey and O’Malley.

Results

A total of 44 studies conducted in 21 countries worldwide were included in the final analysis. Key data were extracted and analysed using thematic analysis, and the following themes have been identified: (1) accessibility and convenience, (2) health anxiety, (3) uncertainty and knowledge gaps in healthcare services, (4) external advice and encouragement, and (5) personal influences.

Conclusion

Our study maps the existing international literature to inform researchers and policymakers on possible future development of efficient alternative care frameworks and pathways designed to alter emergency care utilisation behaviours, ultimately reducing unnecessary visits and ensuring efficient care is provided for true emergencies.

Key messages.

• Thematic analysis of 44 studies across 21 countries generated five major themes: accessibility and convenience; health anxiety; uncertainty and knowledge gaps in healthcare services; external advice and encouragement; and personal influences.

• Integration between primary and emergency care systems is important in developing appropriate clinical care pathways that not only meet patients’ needs but also facilitate the sustainable functioning of both systems.

• Insights into the factors contributing to low acuity ambulance service presentations represent a gap in the literature, warranting further research.

Introduction

Emergency Departments (EDs) are hospital-based emergency medical care settings intended to manage a wide range of unpredictable, emergent and time-critical medical problems requiring immediate care and attention. Emergency ambulance services (EAS) are designed to respond to patients in the community with time-critical health problems, providing initial treatment and rapid transfer to the ED [1]. Together, EDs and EAS represent core components of the “emergency care system”. This system aims to ensure patients receive prompt, appropriate treatment and offers continuous access to unscheduled care for urgent medical complaints [2]. However, emergency care systems globally are experiencing capacity challenges [3], which are compounded by individuals utilising EDs and EAS for conditions that could be managed in primary care [4]. Research has found that the use of emergency services is increasing at a faster rate than population growth [4–7]. For instance, in Victoria, Australia, while the demand for ambulances is increasing, many cases are not emergencies and ultimately involve the use of non-emergency transport services or redirecting callers to alternative health services [5]. This global phenomenon is creating strain on the emergency care system, leading to overcrowding, inefficient use of healthcare resources, and inadequate access to emergency care for those most in need [8].

When individuals seek emergency care for “primary care problems”, this could be considered clinically unnecessary, i.e. when patients access healthcare services beyond their clinical need or level of urgency [9–11]. For instance, Fatima et al. reported that up to 48% of the ED attendances were classified as “GP (general practice)-type visits” in Mount Isa, Australia [12]. In Singapore, Oh et al. reported 9.6% of ED attendances were considered inappropriate [13]. The existing literature has highlighted various reasons for this phenomenon, however, much of the literature has focused on specific healthcare systems or patient groups within one country [4, 14–17], and commonly shared themes across different jurisdictions warrant further exploration.

Several previous literature reviews have considered the issue of emergency care utilisation for primary care problems, however, defining such problems has proven challenging, and approaches are heterogeneous [18, 19]. There is also the issue of initially undifferentiated symptoms and presentations, which can have a wide range of progression, including serious outcomes like death and long-term morbidity [15]. Identifying low-risk patients can be challenging initially [20], and the medico-legal system encourages risk aversion and over-triage [21].

The most recent review that focused specifically on ambulance service utilisation was conducted by Booker et al. in 2015 [22]. A comprehensive realist synthesis of “clinically unnecessary” use of emergency and urgent care was conducted by O'Cathain et al. in 2020 [23]. There have been significant developments both in healthcare delivery and care-seeking behaviour during and in the aftermath of the COVID-19 pandemic [24]. For instance, telemedicine approaches have been adopted in many countries to reduce reliance on the traditional emergency care system [25]. While telemedicine may have improved accessibility of care, it has also introduced new challenges, such as increased workload leading to GP burnout [25]. Given such recent developments, we sought to conduct an up-to-date scoping review of the literature. Our aim was to explore the multifaceted factors contributing to patients’ decisions to seek emergency care for conditions that could be managed in primary care. Furthermore, we also sought to identify gaps in existing literature and ultimately inform a future programme of research that will address this issue.

Methods

To acquire a comprehensive overview of the literature on why patients seek emergency care for “non-urgent” or “acute problems that could be managed in primary care”, we employed scoping review methodology to map the existing literature. This was conducted using the methodological framework presented by Arksey and O’Malley, which is set out below [26]. Our objectives were to identify key concepts and highlight existing research gaps in this field.

Stage 1. Identification of the research question

The following research question was developed to consider literature exploring behaviour and motivation regarding the use of emergency care services, “What are the factors influencing patients’ decision-making process in seeking emergency care for problems that could be managed in primary care?”

Stage 2. Identification of relevant studies

The initial phase of database searching involved several preliminary searches using search terms that were further developed and modified to iteratively formulate a comprehensive final search strategy (Supplementary S1 PubMed search strategy). This final search strategy was then adapted to meet the specific requirements of different online databases. The final search terms were categorised around the constructs “emergency care”, “primary care”, and the “underlying reasons contributing to utilisation”.

A comprehensive search of “PubMed”, “Embase”, “MEDLINE”, “CINAHL” and “the Cochrane Library” was conducted in June 2024. This sought to include peer-reviewed articles published from January 1st 2004, until June 15th 2024. This period was selected in order to provide both a recent and comprehensive overview of the literature. Hand searches of the reference lists of previous literature reviews of the topic were also conducted. For the purposes of this study, we defined children to be individuals aged 17 years and under, adults as individuals aged 18 years and older, and older adults as individuals aged 65years and above.

Stage 3. Studies selection

Following the searches, all search results were imported into EndNote version 21 software. Screening of articles was conducted manually and sequentially in three steps to ensure only relevant studies were included for analysis: (1) deduplication, (2) title and abstract screening, (3) full-text article screening. The principal author (AC) conducted the initial searches, title and abstract screening, and full text review. Where there was any uncertainty, a second author (TB) independently reviewed the studies, with any differences of opinion resolved by discussion.

Inclusion criteria were as follows:

• Published between 2004 and 2024

• Published in the English language

• Studies exploring factors contributing to patients’ decisions to visit the ED or call an ambulance with an issue that was considered suitable for management in primary care

Exclusion criteria were as follows:

• Conference abstracts, protocols, editorials, letters to the editor

• Studies focusing on hospital admissions

• Studies exclusively involving paediatric populations

Stage 4. Data charting

Once all articles relevant to our research question were identified, the following information was summarised and charted:

• Author and year

• Study title

• Country and setting of data collection

• Methodology

• Age and number of participants involved in each study

• Aim

• Main findings

Stage 5. Collating, summarising, and reporting results

The factors influencing patients’ decision-making process in seeking emergency care for problems that could be managed in primary care that were identified from the literature were analysed and summarised across key themes by adopting Braun and Clarke's thematic analysis method [27–29]. Six phases of thematic analysis were undertaken, which involved familiarisation with the literature, initial codes being generated, the development of themes, refinement, and the production of a thematic map. Finally, a report was produced.

Stage 6. Consultation

A consultation exercise was not conducted at this stage of the research process. However, follow-up research based on the results of this study is ongoing and will involve a comprehensive stakeholder consultation considering how the results apply to the Irish context.

Results

The PRISMA scoping review flow diagram summarises the study selection process for this review (Fig. 1). Comprehensive searches of “PubMed”, “Embase”, “MEDLINE”, “CINAHL” and “the Cochrane Library” identified 2513 results. Following duplicate removal and thereafter title, abstract and full text screening, 42 eligible studies were identified. Additionally, two articles were identified from hand searches. Hence, 44 studies were identified for final inclusion.

Figure 1.

PRISMA flow diagram illustrating study selection process.

Study characteristics

The included studies are summarised in Table 1.

Table 1.

Included studies analysing emergency care-seeking behaviour among patients.

Author, year	Title	Country	Setting	Methodology	Participants	Aim	Main findings
Northington et al, 2005 [4]	Use of an emergency department by non-urgent patients	USA	Central North Carolina	Survey (paper-based) & interview (verbal)	279 adults	To investigate ED usage by non-urgent self-referred patients and whether these patients have a primary care provider or are aware of alternative services to the ED.	Most respondents who visited the ED had a regular GP, however, 27% of these patients are reported to rely on the ED for the entirety of their medical needs. The three most common reasons identified were: (1) the perception that higher quality of care was provided, (2) perceived urgency for their complaint, and (3) immediate attention received. Additional reasons cited include (4) flexible payment options, and (5) convenience, as EDs operate 24 hours a day, unlike primary care services, which require pre-scheduled appointments.
Ahl et al, 2006 [19]	Making up one's mind:—Patients’ experiences of calling an ambulance	Sweden	Towns and rural areas of southern Sweden	Interview (verbal)	20 adults	To explore patients’ experiences on the decision-making process behind calling an ambulance, determining the appropriateness of ambulance usage, and to obtain a broader picture of their overall situation, the moment they called an ambulance	Two main themes were identified: “making up one's mind” and “waiting for help”. Among these themes, factors identified included: (1) the need for help immediately due to an intolerable situation, with stress and pain relieve upon knowing an ambulance is on their way, (2) external encouragement, (3) understanding one's limitation and acknowledging benefits of calling an ambulance such as minimising burden on friends and family, (4) the perception of ambulance as the safest, fastest and most secure way for immediate care with the expectation of high priority given upon arrival at ED, (5) fear and loneliness, driving an urgency to reach the hospital as quickly as possible, (6) the desire to avoid responsibility while feeling relieved, safety and trust in professional care.
Yarris et al, 2006 [30]	Reasons Why Patients Choose an Ambulance and Willingness to Consider Alternatives	USA	Oregon	Survey (paper-based)	315 patients (all ages)	To analyse reasons why patients decided to use ambulance services and their willingness to consider alternative services to ambulance transport.	Reasons identified included: (1) a call made by someone else, (2) paramedic recommendation, (3) lack of alternative transport to ED, (4) availability of immediate care, (5) a life-threatening emergency, (6) uncertainty about the necessity of seeking medical attention, (7) shorter waiting times, (8) did not have a doctor, (9) lack of health insurance.
Norredam et al, 2007 [14]	Motivation and relevance of emergency room visits among immigrants and patients of Danish origin	Denmark	Copenhagen	Survey (paper-based)	3426 patients (all ages)	To compare the motivations for seeking ED treatment between immigrants and Danish patients, and the differences in ER claims between these two groups.	The primary reasons for choosing the ED were: (1) inability to secure an appointment or contact a GP, (2) perception that ED was the most appropriate service, and (3) referral by a primary caregiver. Additionally, 50% of respondents reported additional factors, including: (4) preference for the ED, (5) difficulty describing their complaint over the phone, (6) the need for help despite residing far away, and (7) better access to specialist services in the ED.
Moll van Charante et al, 2008 [31]	Self-referrals to the A&E department during out-of-hours: patients’ motives and characteristics	Netherlands	Ijmuiden	Survey (postal)	224 patients (all ages)	To investigate self-referred patients’ reasoning to visit the ED; and compare their characteristics to patients contacting the GP by using logistic regression analysis.	The main reasons identified were: (1) the need for diagnostics such as X-Rays, (2) belief that ED offers better quality care, (3) the perception that ED doctors are more suitable for their needs, (4) ED being more accessible than GP services, (5) ED visits related to recent hospital procedures and follow-ups, and (6) GP unavailability.
Steele et al, 2008 [32]	Rural emergency department use by CTAS IV and V patients…Canadian Triage and Acuity Scale	Canada	Exeter, Ontario	Survey (paper-based)	137 patients (all ages)	To explore whether the same reasons apply to patients with low-acuity problems in a rural ED compared to those in a tertiary care ED.	Reasons identified were: (1) prompt treatment, (2) availability of specific services such as radiography, suturing, casting, and intravenous medications, (3) closure of walk-in clinics, (4) long wait times, (5) inability to secure an appointment with a GP, and (6) lack of a regular GP.
Redstone et al, 2008 [33]	Non-urgent use of the emergency department	USA	Aurora	Survey (paper-based)	240 adults	To understand why patients with primary care providers choose to attend the ED for non-urgent problems, compare the results between weekday day groups and non-weekday day groups, and hence identify solutions to reduce ED overcrowding.	Reasons reported were: (1) ED was seen to be more convenient than their primary care provider, (2) 60% of surveyed patients found it easier to secure a near-term appointment, (3) unavailability of timeslots during office hours, (4) no need to schedule appointments for ED, (5) primary care provider location was not nearby, (6) perceived urgency and complexity of their problems.
Graham et al, 2009 [34]	Preferences and perceptions of patients attending emergency departments with low acuity problems in Hong Kong	China	Hong Kong	Interview (verbal)	249 patients aged 15+	To identify reasons for HK patients visiting the ED and how patients prefer to receive waiting time updates.	The main reasons identified included: (1) the need for comprehensive examinations, (2) the belief that healthcare providers in ED can provide more expert medical advice, (3) the benefit of continuous care in the hospital, and (4) referrals from other healthcare professionals.
Durand et al, 2012 [35]	Non-urgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients	France	Provence-Alpes-Côte d’Azur (PACA)	Interview (semi-structured, verbal) & survey	121 adults (87 patients and 34 health professionals)	To identify why people with non-urgent medical needs seek care from the ED, and the perspectives of the “nonurgency” from ED health professionals.	Reasons identified: (1) ED addresses and fulfils patients’ health needs effectively, (2) barriers in accessing primary care services, and (3) advantages of the ED's setting and environment.
Marco et al, 2012 [36]	Access to care among emergency department patients	USA	Toledo	Interview (verbal)	292 adults	To explore the factors affecting patients’ decisions to visit the ED and evaluate their access to primary care.	Most respondents were found to have GPs, but only a minority called them about their current complaint. The primary reasons for ED visits included: (1) convenience due to its location, (2) personal preference for the institution, (3) referral by their GP, (4) the GP's connection to the hospital, (5) inability to secure an appointment with the GP, (6) perceived emergency of the condition, (7) EMS transport.
Shaw et al, 2013 [37]	Decision-making processes of patients who use the emergency department for primary care needs	USA	New Jersey	Interview (semi-structured, verbal)	30 adults aged 21+ who are residents of New Jersey	To explore the reasons and decision-making process of patients visiting the ED, their satisfaction with the care received, and the influence of insurance and demographics on ED use.	The study revealed significant differences in decision-making processes depending on whether patients were aware of primary care options but chose the ED, or were unaware of alternative medical services. Reasons for choosing the ED over primary care included: (1) advice from a medical professional, (2) barriers to accessing regular care, such as transportation challenges and lack of efficiency, (3) issues related to racial matters at public health clinics, (4) uncertainty about the definition of emergency, and (5) concern about the cost of care.
Booker et al, 2014 [20]	Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process	UK	Great West Ambulance Service NHS Trust catchment area	Interview (semi-structured, verbal)	16 adults	To understand factors influencing patient and carer decision-making when choosing to dial 999	Factors affecting the decision to dial 999 included: (1) perceived urgency, (2) patient and carer anxiety in the urgent decision-making process, (3) factors related to previous experiences with urgent care, and (4) interpersonal factors and risk assessment.
Sharp et al, 2014 [38]	Exploring real-time patient decision-making for acute care: A pilot study	USA	Pasadena, California	Survey (text responses)	20 adults	1) To understand when participants decide if healthcare is needed, primarily for low-acuity conditions; 2) to describe where patients choose to seek care for different conditions; 3) to examine factors influencing decision-making; and 4) to examine how preferences and perceptions influence decision-making.	Reasons identified were: (1) Perceived severity, (2) length of symptoms, and (3) inability to secure an appointment at primary care were found to be important influencers to attend the ED.
van der Linden et al, 2014 [39]	Self-referring patients at the emergency Department: appropriateness of ED use and motives for self-referral	Netherlands	The Hague	Interview (verbal)	5003 patients (all ages)	To explore ED usage by assessing characteristics of self-referrals and non-self-referrals, their need for hospital emergency care, and the reasons behind self-referrals to the ED	Reasons identified were: (1) easy accessibility and convenience of the ED, (2) perceived necessity to seek care from ED, (3) lack of consideration about visiting a GP, (4) lack of a regular GP, (5) familiarity, (6) dissatisfaction with the GP, (7) advice from non-professionals, and a minority of respondents mentioned language barrier as a challenge.
Curoe et al, 2015 [40]	A Day in the Life of an Urban Emergency Department	USA	Setting not specified beyond “urban ED’	Interview (verbal)	67 patients (all ages)	To investigate the factors leading to nonemergent use of hospital EDs	Reasons for ED visits were: (1) perceived emergency, (2) no appointment required, (3) inability to secure an appointment at primary care centres, (4) preference for ED, and (5) transportation available to the ED.
Faulkner et al, 2015 [11]	The “unnecessary” use of emergency departments by older people: findings from hospital data, hospital staff and older people	Australia	Adelaide	Review of hospital data for 65+ populations, focus groups, and survey responses (telephone)	∼2355 older patients (data review), 30 staff (focus group), 58 older patients (survey)	To compare administrative data and views of healthcare staff and older people, and to consider alignment with the Australian Institute of Health and Welfare definition of “potentially avoidable general practitioner-type presentations.’	Reasons for ED visits were: (1) perceived severity or urgency, (2) ED being the only place open, (3) referral to ED by a GP, (4) visiting the ED on a weekend, (5) inability to access a GP, (6) the ED's being more well-equipped with their facilities, and (7) dissatisfaction with previous attempts to seek care at a medical clinic.
Atenstaedt et al, 2015 [41]	Why do patients with nonurgent conditions present to the Emergency Department despite the availability of alternative services?	UK	North Wales	Survey (paper-based)	806 patients (all ages)	To analyse the reasons why non-urgent patients did not visit other alternative healthcare service providers before going to the ED.	Reasons for ED visits were: (1) the need for specific diagnostics or treatments such as X-Rays, tetanus shot, blood test and stitches, (2) did not want to bother or the perception that GP could not provide help they wanted, (3) unavailability of GP or lack of regular GP, (4) lack of awareness of alternative healthcare service providers, (5) ED was at a closer proximity and quicker service provided, (6) wanted a second opinion about their condition, (7) preference to visit a specialist at the hospital.
Beache et al, 2016 [2]	Non-urgent accident and emergency department use as a socially shared custom: a qualitative study	Saint Vincent and the Grenadines	Saint Vincent	Interview (semi-structured, verbal)	12 adults	To explore the attitudes of ED patients with non-urgent complaints, to understand their reasons for seeking emergency care and their reluctance to use primary care services	Reasons for ED visits were: (1) habitual use of ED, including automaticity, uncertainty about which service to use, and social encouragement, (2) systematic encouragement of ED use, including unmatched schedules, types of professionals seeking, perception that primary care staff refer patients to ED, dissatisfaction with the staff behaviour, and cost effectiveness, and (3) intentional use of ED, including convenience, perceived urgency, positive previous ED experience and confidence.
Cheek et al, 2016 [10]	Low-acuity presentations to regional emergency departments: What is the issue?	Australia	Tasmania	Retrospective sub-analysis of ED data and Survey (cross-sectional)	255 365 patients (all ages)	To explore GP-referrals and self-referrals to EDs and examine the factors affecting patients’ decision to seek low-acuity care at ED, and the most common 10 conditions presented to ED	One-stop care was found to be an influential factor. Reasons for ED visits were: (1) the ability to see a doctor and undergo tests or X-rays in the same place as the ED, and (2) the closure of GP surgery. Other reasons included: (3) long wait time, (4) inability to secure an appointment with their GP, (5) proximity of ED to work or home, (6) better treatment at ED, (7) perception that GP would send them away, (8) lack of a regular GP, (9) referral from GP to ED, (10) habitual use of ED, (11) lack of required equipment at the GP, (12) preference for a hospital setting, and (13) wanted a second opinion other than their GP.
Schmiedhofer et al, 2016 [42]	Patient motives behind low-acuity visits to the emergency department in Germany: a qualitative study comparing urban and rural sites	Germany	Berlin (urban) and Saxony-Anhalt (rural)	Interview (semi-structured, verbal)	64 adults	To investigate the motives of patients categorised with low-acuity conditions for visiting the ED, while investigating differences between urban and rural EDS	Motives included: convenience related to time, work duties, and the need for specific interventions like X-Rays, with the perception that the ED is of a higher quality and more well-equipped, and health anxiety due to unavailable time or referral by a GP for challenging symptoms.
Enard et al, 2017 [43]	Exploring the Value Proposition of Primary Care for Safety-Net Patients Who Utilize Emergency Departments to Address Unmet Needs	USA	Houston/Harris County, Texas	Survey (paper-based)	329 adults	To explore the factors associated with low-acuity ED visits and identify differences in patients’ use of emergent versus non-emergency usual source of care. To assess patients’ knowledge of patient-centred medical homes.	Reasons for ED visits were: (1) perceived severity of health condition requiring immediate help, (2) lack of awareness of alternative services, (3) availability of delayed payment options, (4) flexibility of ED's opening hours, (5) perception of higher quality of care, (6) convenient location within the hospital, (7) broader range of services available due to “one-stop shopping”, and (8) inability to secure an appointment with another doctor or urgent care centre.
Coe et al, 2018 [44]	Low-Income Senior Housing Residents’ Emergency Department Use and Care Transition Problems	USA	Central Virginia	Interview (semi-structured, verbal)	14 older patients	To analyse characteristics of older or disabled adults in low-income senior housing, and their thinking process and reasons leading to ED visits. Additionally, this study identifies issues that arise when they transition back home from the ED.	Reasons for ED visits were: (1) symptoms persisting for varying duration (2.5 hours, 24 hours, or a few weeks), (2) onset of new symptoms on the same day, (3) sudden onset of symptoms or illness, (4) high blood pressure management, (5) worsening conditions affecting daily routine, (6) intermittent symptoms, and (7) discomfort after injury.
Bahadori et al, 2019 [45]	Emergency department visits for non-urgent conditions in Iran: A cross-sectional study	Iran	Tehran	Survey (paper-based)	1217 patients (all ages)	To investigate the reasons why patients choose ED for non-urgent conditions. Additionally, evaluate the relationship between the characteristics of patients and their decision to visit the ED.	Reasons for ED visits were: (1) timely care, (2) cost-effectiveness, (3) availability of respondents’ medical records at the hospital, (4) convenient proximity, (5) clinic referral, (6) perceived urgency, (7) higher quality of care, (8) closure of other medical centres when care was needed, (9) dissatisfaction with clinics, (10) personal or familial employment at the hospital, and (11) transport to the ED by ambulance.
Ghazali et al, 2019 [46]	Profile and Motivation of Patients Consulting in Emergency Departments While Not Requiring Such a Level of Care	France	Paris	Survey (paper-based)	598 adults	(1) To explore sociodemographic characteristics, access to services and reasons why these patients visit the ED, (2) To explore whether patients could be referred to their primary care physicians without consulting an ED physician, and their satisfaction with ED consultations.	Reasons for ED visits were: (1) need for additional testing (e.g. blood tests and imaging), (2) inability to secure an appointment with a GP, (3) convenient proximity, (4) advice or referral by other health professionals, (5) need for care outside of working hours, (6) severe pain, (7) no upfront payment required, (8) second opinion required about their condition, (9) previous care received at the hospital, (10) workplace accidents, (11) the need for hospitalisation, and (12) advice from peers.
Goodridge et al, 2019 [47]	Understanding why older adults choose to seek non-urgent care in the emergency department: The patient's perspective	Canada	Saskatoon	Interview (semi-structured, verbal)	115 older patients	To assess older adults’ knowledge, expectations, and reasons for visiting the ED	Reasons for ED visits were: (1) Easy accessibility, (2) flexible availability during “off-hours”, (3) perception that ED offers higher quality of care than primary care, and (4) positive past experiences. Additionally, respondents cited reasons such as, (5) referrals to ED by their GP or specialists, (6) the comprehensiveness of ED, (7) the convenience of having diagnosis and treatment in one location, and (8) a lack of awareness of alternative healthcare services for non-urgent complaints.
Henninger et al, 2019 [48]	Deciding whether to consult the GP or an emergency department: A qualitative study of patient reasoning in Switzerland	Switzerland	Northern canton of Vaud	Interview (semi-structured, verbal)	20 adults	To examine the factors influencing patients’ decisions when facing self-perceived urgent problems, and to determine whether they choose to visit a GP or the ED.	Reasons for ED visits were: (1) perceived severity of condition, (e.g. intense pain) (2) the need for quick responses and consultations, (3) preferences to seek care outside of work hours, (4) comprehensive equipment and facilities, (e.g. X-Rays), (5) 24-hour service, seven days a week, and (6) access to specialists.
Minderhout et al, 2019 [49]	Understanding people who self-referred in an emergency department with primary care problems during office hours: A qualitative interview study at a Daytime General Practice Cooperative in two hospitals in the Hague, the Netherlands	Netherlands	The Hague, Netherlands	Interview (semi-structured, verbal)	44 patients (all ages)	To investigate the motives for hospital self-referral during GP office hours, and barriers discouraging patients from consulting a GP for primary care problems.	Reasons for ED visits were: (1) lack of knowledge regarding appropriate EMS use and when to contact a GP, (e.g. uncertainty about when to use the GP's emergency number) (2) perception of higher quality of care at ED, (3) proximity, (4) perception of faster care, (5) perceived urgency, (6) parental concern for children, (7) social factors and habitual visits, and (8) barriers to visiting GP, (e.g. not having a GP, far away from a primary care centre, inaccessible of GP, long wait times).
Miyazawa et al, 2019 [17]	Inappropriate use of the emergency department for nonurgent conditions: Patient characteristics and associated factors at a Japanese hospital	Japan	Ibaraki Prefecture	Survey (paper-based)	231 adults	To explore the factors contributing to inappropriate ED visits for low-acuity problems during non-working hours.	Reasons for ED visits were: (1) the need for quicker care, (2) wanted a doctor's assessment and advice, (3) wanted to know about the severity of their condition, (4) lack of improvement in their condition, (5) the need for a medical prescription, (6) wanted laboratory testing, (7) seeking treatment from a specialist, (8) advised by others, (9) non-prescribed medication not working, (10) wanted advice on returning to school or work, (11) wanted an intravenous drip, and (12) inability to leave school or work.
Al-Otmy et al, 2020 [15]	Factors associated with non-urgent visits to the emergency department in a tertiary care centre, western Saudi Arabia: cross-sectional study	Saudi Arabia	KAMC, Jeddah	Survey (verbal)	100 patients (all ages)	To explore the extent and factors leading to non-urgent ED visits in this hospital.	Reasons for ED visits were: (1) perceived urgency, (2) easy access to care, (3) lack of comprehensive services and resources at primary care centres, (4) inability to secure an appointment with a GP, and (5) referral from primary care. Additionally, the study found that imaging (e.g. chest X-ray) and laboratory investigations (e.g. basic screening and troponin testing) were conducted on more than half of visiting patients.
Bornais et al, 2020 [50]	One Stop: Examining the Reasons Patients Use the Emergency Department for Nonurgent Care and the Barriers They Face	Canada	Southwestern Ontario	Interview (semi-structured, verbal)	33 adults	To determine the reasons for non-urgent visits to the ED, and barriers encountered when accessing healthcare.	Three main themes were identified for each research aim. For the first aim, reasons identified were: (1) GP referral, (2) care effectiveness, and (3) time efficiency; In describing the barriers respondents faced when seeking alternate services, three other themes were identified, (1) lack of primary care provider, (2) relative cost effectiveness at ED and (3) insufficient comprehensive care options.
O’Cathain et al, 2020 [9]	Drivers of “clinically unnecessary” use of emergency and urgent care: the DEUCE mixed-methods study	Worldwide & UK	Realist review component: international, interviews: England, focus groups: Britain	Sequential mixed-methods study—Realist review, interviews (verbal) and focus groups	48 patients (all ages, interview), 15 patients (all ages, 3 focus groups), 2906 adults (survey)	To investigate the factors driving “clinically unnecessary” use of emergency medical services (ambulance and ED) and GP appointments, considering the perspectives of both patients and the general public.	The authors found a “supply-demand mismatch”, and that the reasons driving decision-making processes were interdependent: (1) concern about severity of symptoms, (2) inability to continue with their daily tasks and wish to return to normal routines, (3) need for rapid symptom relief, (4) prolonged waiting without seeing improvement, (5) difficulty managing health issues due to mental health problems and stressful lives, (6) fear of feeling guilty towards others, (7) compliance to social networks, (8) perception or previous experiences of various health services, (9) lack of timely access to a GP, (10) recommendation from other health professionals.
Almulhim et al, 2021 [51]	Preference for Visiting Emergency Department Over the Primary Health Care Centre Among Population in Saudi Arabia	Saudi Arabia	Kingdom	Survey (online)	915 patients (all ages)	To explore factors affecting patients’ decisions to visit the ED rather than primary care for non-urgent complaints, and to assess respondents’ understanding and awareness of ED services.	Nearly half of the respondents (49.6%) preferred to visit the ED. The five most reported reasons were: (1) prompt medical attention, (2) ease of access to emergency care, (3) inability to secure primary care same-day appointments, (4) insufficient diagnostic services provided in primary care centres, and (5) lack of primary care providers.
Brasseur et al, 2021 [52]	Emergency department crowding: why do patients walk-in?	Belgium	Liege	Survey (paper-based)	1999 patients aged 16+ (or <16 with relative)	To identify drivers, characteristics, pathways, and justifications for ED walk-in patients preferring the ED over primary care.	The study found that most ED patients are self-referred. Reasons for ED visits were: (1) perceived emergency of conditions, hence requiring ED service, (2) easy accessibility and timely care provided at the ED, (3) immediate specialised care available or patients perceive the need for a specific service from the hospital on the same day, (4) hospital reputation, and (5) stress.
de Freitas Machado Gonçalves et al, 2021 [53]	Motivations of user access in situations characterised as non-urgent ready	Brazil	Rio Grande do Sul	Interview (semi-structured)	21 adults	To determine drivers for patients’ non-urgent ED visits.	Reasons for ED visits were: (1) shortage of medical healthcare professionals in basic health units (UBS), (2) inadequate capacity and resources at UBS to provide efficient care, (3) insufficient opening hours of UBS, or misalignment with patients’ schedules, (4) long waiting time, (5) demand for consultations exceeds the number of slots available, (6) convenience and ease of completing medical examinations and receiving medications, (7) perception that ED offers higher quality of care and quicker care, and (8) dissatisfaction with the quality of care provided in primary care services.
Fatima et al, 2021 [12]	Drivers of general practice–type presentations to the emergency department in a remote outback community	Australia	Mount Isa	Case study, Review of patient records & Prospective survey	400 (all ages, data review), 369 adults (survey)	To quantify the number of GP-type visits in a remote ED and investigate the reasons behind patient decisions.	As high as 48% of all ED attendances were classified as “GP-type visits” based on previously defined criteria. Reasons for ED visits were: (1) self-perceived urgency, (2) convenience, and (3) costs. From the regression results in an adjusted model, (4) education, and (5) unavailability of local GP services were found to be important factors. Additionally, (6) awareness and accessibility, (7) affordability, (8) acceptability, and (9) effectiveness were all factors found to contribute when health service decisions are being made.
Matifary et al, 2021 [54]	Reasons for patients with non-urgent conditions attending the emergency department in Kenya: A qualitative study	Kenya	Nairobi	Interview (semi-structured, verbal)	24 adults	To explore (1) why patients choose the ED for non-urgent health complaints, (2) their knowledge about the roles of the ED, and (3) their views on the definition of urgency.	Reasons for ED visits were: (1) a preference towards visiting the ED, (2) satisfaction from previous experience due to efficient care provided, (3) the belief that ED is better equipped than other health departments, hence providing better quality care, (4) longer operating hours compared to other health settings, (5) uncertainty about where to seek specific services, and (6) hospital reputation. This study also found that some respondents consider the ED an appropriate place to go regardless of the severity and urgency of their health complaints. Lastly, (7) perceived urgency was a significant factor, as most respondents thought their condition was life-threatening and preferred not to take any risks, even if their condition was not critical.
Pförringer et al, 2021 [55]	Emergency room as primary point of access in the German healthcare system: Objective evaluation and interview of motivation for ER entrance of 235 ER patients in a German hospital	Germany	Munich	Survey (paper-based) & Interview	235 patients (all ages)	To explore patients’ motivations for ED attendance.	Reasons for ED visits were: (1) immediate assistance provided, (2) quick treatment and care from specialists, (3) comprehensive diagnostic facilities, (4) convenience and easy accessibility, (5) satisfaction from previous experience, (6) high-quality care and treatment, and (7) lack of access to a GP.
Tapia et al, 2021[56]	Assessing Challenges with Access to Care for Patients Presenting to the Emergency Department for Non-Emergent Complaints	USA	San Antonio, Texas	Survey (paper-based)	208 adults	To investigate reasons contributing to patients with non-emergency issues visiting the ED, and to provide potential solutions regarding these reasons.	Most reported reasons included: (1) self-perceived emergency and urgency, (2) unavailability of near-term health appointments at the GP, (3) the need for specific diagnostics and treatments such as X-Ray and laboratory studies
Cummins et al, 2022 [8]	The “better data, better planning” census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland	Ireland	(5 hospitals spread across Ireland)	Review of electronic records and survey	306 adults	To explore the factors driving ED visits in Ireland, and to provide a summary of the demographic and clinical profile of patients.	Reasons for ED visits were: (1) referral from community services, (2) patients’ knowledge and awareness of alternative emergency care pathways, (3) general reasons for ED visits, (e.g. perception that the ED was the most appropriate service to seek help from, and advice from family members), and (4) specific reasons for ED visits, (e.g. perceived emergency, the need for specific medical interventions like X-Rays or scans, belief that they need to visit a hospital, seeking reassurance, or wanting to be checked by a doctor or nurse as soon as possible).
Fatima et al, 2022 [57]	Why patients attend emergency department for primary care type problems: views of healthcare providers working in a remote community	Australia	Mount Isa	Focus groups and interviews (semi-structured, verbal)	24 healthcare professionals (focus group and interview)	To explore the opinions of ED and GP healthcare providers towards ED use for GP-type complaints in a small and remote city in Australia	Reasons for ED visits were: (1) barriers and difficulty in accessing GP care, (2) patient decision-making factors related to convenience, time, and costs, and (3) patients’ self-perceived needs, urgency, and emergency. Notably, health literacy was found to influence patient decisions when choosing care pathways.
Korczak et al, 2022 [58]	Understanding patient preferences for emergency care for lower triage acuity presentations during GP hours: a qualitative study in Australia	Australia	Sydney	Interview (semi-structured, verbal)	44 adults	To explore the factors influencing patients’ preference to visit the ED for low-acuity health complaints during GP working hours.	Four main themes of reasons were identified: (1) referral and advice from others, including healthcare providers, colleagues, friends or family members, (2) factors related to the ED, (e.g. ED's convenience for various investigations, perceived severity of condition hence a decision to attend the ED), (3) factors related to GP, (e.g. lack of a regular GP, unable to secure an appointment with a GP, or dissatisfaction with previous GP experiences), (4) personal factors, (e.g. a personal connection to the hospital).
Mahmoud et al, 2022 [59]	Knowledge and attitude towards emergency department utilization in Riyadh	Saudi Arabia	Riyadh	Survey (online)	440 adults	To assess patients’ knowledge and perceptions of the ED and analyse the general public's views towards the use of the ED in Riyadh.	Reasons for ED visits were: (1) longer operating hours at ED, (2) more medical services and resources at ED, (3) lack of primary care centre access in Riyadh.
Yang et al, 2023 [60]	Pacific patients’ reasons for attending the emergency department of Counties Manukau for non-urgent conditions	New Zealand	Counties Manukau (South Auckland)	Survey (paper-based) & interview (verbal)	353 patients (all ages)	To investigate the reasons why Pacific patients presented to the ED for non-urgent problems.	Reasons for ED visits were: (1) advice from others to visit the ED, (2) unavailability of usual care services, (3) no improvement in condition, (4) severe symptoms, (5) lack of awareness about the location of after-hour clinics, (6) lack of trust towards their regular GP, (7) convenient location of ED, (8) cost effectiveness.
Tuz et al, 2024 [16]	Why patients self-refer to the emergency service for nonurgency?: A mix-method survey from a family medicine perspective	Turkey	Erzincan	Survey (paper-based)	325 adults	To explore the reasons and characteristics of the adults attending or self-referring to ED for non-urgent complaints, and the relationship between these patients and their GP.	Main reasons identified were: (1) perceived urgency and emergency, (2) efficiency and easy access to the ED, (3) disadvantages of primary care (e.g. difficulty securing appointments and dissatisfaction with the GP), (4) specific interventions required from the ED (e.g. intravenous treatment).

The included studies were conducted across a variety of geographical settings (Fig. 2 and 3), most frequently the United States of America (n = 10) [4, 30, 33, 36–38, 40, 43, 44, 56], followed by Australia (n = 5) [9, 10, 12, 57, 58], Netherlands (n = 3) [31, 39, 49], Canada (n = 3) [32, 47, 50], Saudi Arabia (n = 3) [15, 51, 59], United Kingdom (n = 2) [20, 41], France (n = 2) [35, 46], Germany (n = 2) [42, 55], Denmark (n = 1) [14], Hong Kong SAR of China (n = 1) [34], Saint Vincent and the Grenadines (n = 1) [2], Iran (n = 1) [45], Switzerland (n = 1) [48], Japan (n = 1) [17], Belgium (n = 1) [52], Brazil (n = 1) [53], Kenya (n = 1) [54], Ireland (n = 1) [8], Turkey (n = 1) [16], Sweden (n = 1) [19], and New Zealand (n = 1) [60]. One study involved multiple countries [11]. The year of publication of these included studies ranged from 2005 to 2024.

Figure 2.

Geographic representation of studies included in the scoping review.

Figure 3.

Bar chart distribution of studies included.

Three studies specifically focused on reasons for using ambulance services [19, 20, 30], while one addressed both ambulance and ED services [11]. Of the included studies, 22 focused on adults only, including three studies focused specifically on older adults, and the remainder collected information concerning participants in all age groups (children, adults, and older adults). Ten studies used a mixed-method approach combining both quantitative and qualitative analyses [4, 8, 10, 11, 16, 31, 38, 39, 52, 60]. Fifteen studies used a quantitative approach [9, 12, 14, 15, 17, 32–34, 41, 43, 45, 49, 51, 55, 59], and 19 studies used a qualitative approach [2, 19, 20, 30, 35–37, 40, 42, 44, 46–48, 50, 53, 54, 56–58]. Four of the studies analysed retrospective health data [8–10, 12]. Regarding participant perspectives, three studies included responses from staff or health professionals [10, 35], while all other studies included responses from patients only.

Thematic analysis

Following thematic analysis, the following themes were generated (Fig. 4): (1) accessibility and convenience, (2) health anxiety, (3) uncertainty and knowledge gaps in healthcare services available, (4) external advice and encouragement from other parties (including GP referrals and opinions from family and friends) and (5) personal influences (including patient satisfaction based on previous use of emergency medical services).

Figure 4.

Thematic map.

Accessibility and convenience

Ease of access and convenience were commonly reported reasons for patients utilising EDs. The availability of 24-hour services [2, 4, 10, 33, 43, 45–48, 53, 54, 59] and the ability to seek care immediately without pre-booked appointments [40] made EDs a preferred option over GP clinics, where “securing timely appointments was difficult” [12, 35, 58]. The comprehensive availability of “one-stop shopping” at EDs was an attractive feature for individuals with health concerns [9, 10, 43, 48], including the comprehensiveness of care offered, the convenience of medical examinations, and the specific elements available such as X-Rays, intravenous treatment and laboratory testing [8, 15–17, 31, 32, 41, 42, 46, 48, 56]. Such facilities were thought to reduce the need for multiple bookings with different healthcare professionals [47]. Due to high healthcare service demand exceeding the corresponding supply, a shortage of available appointments with GPs further limited access, reinforcing ED use [9, 14–16, 32, 33, 36, 38, 40, 41, 46, 51, 57, 58]. Additionally, geographical proximity and financial considerations such as lower cost of care, alongside flexible and delayed payment options, also contributed to the decisions to visit the ED versus other alternatives [2, 12, 37, 45, 50, 57, 60].

Health anxiety

The literature suggests that some patients prefer to seek a second opinion from other medical professionals, hence the decision to visit the ED [9, 41, 46]. Many studies highlighted patients’ description of their symptoms as urgent, emergent, or severe, driving them to believe that emergency care was needed [2, 4, 8, 10, 12, 15–17, 19, 20, 33, 36, 38–40, 43, 45, 48, 49, 52, 54, 56–58]. Furthermore, sudden onset of symptoms or prolonged waiting periods without seeing improvements, as well as worry about the impacts on their daily routines, led patients to seek reassurance from medical professionals in the emergency care setting [11, 17, 38, 44, 46, 60], as did the worry of needing to make urgent decisions [20, 52]. Confidence in medical care also played a role in care-seeking behaviour, where patients might associate hospitals with a higher reputation and higher quality of medical care provided, or they wish to consult a medical specialist [41, 52, 54].

Uncertainty and knowledge gaps in healthcare services

A lack of knowledge or awareness about health services available may leave patients unclear about their care options, hence the habitual default use of the ED for all health complaints [37]. Additionally, many patients may not be aware of the appropriate way to access health services other than EDs [2, 8, 12, 41, 43, 47, 49, 50, 54, 60]. Misconceptions about GPs, where some patients were concerned about GPs referring them away, may also play a role [2].

External advice and encouragement

Advice from family, peers and colleagues could impact patient choices, leading to patients seeking alternative care options [8, 17, 39, 46, 58, 60]. Referrals from GPs, paramedics, nurses at a health information hotline, and community services to the ED could also influence patients’ decision-making, particularly when they are uncertain about the severity of their symptoms [8, 30, 50]. In terms of ambulance usage, when a third party dialled the local emergency number on behalf of the patient, the patient might not have recognised a need for help urgently [19, 30].

Personal influences

Patients who felt satisfied with efficient medical care provided at the ED were more likely to return to the ED for future health needs [2, 10, 11, 20, 31, 46, 47, 54, 55]. On the other hand, patients’ dissatisfaction with a previous visit to a GP [10, 39, 45], for reasons due to staff behaviour and perceived poor quality of care provided, was noted [2, 16, 39, 53, 58]. Social factors such as language barriers, fear of guilt and judgement, and cultural and ethnic factors in terms of how patients seek care from a GP were highlighted, for example, decisions to avoid GP clinics could be due to perceived individual or community biases, where patients would report discomfort with the clinic's ethnic composition, and expressed concerns regarding care provided [37, 39]. These factors led some individuals to avoid GP clinics and turn to emergency care instead. Rapport with health professionals and those who had personal connections, such as personal or familial employment at the ED or hospital, were also drivers of ED utilisation [45, 58].

Discussion

We conducted a comprehensive scoping review to provide an updated overview of key literature considering “why patients seek emergency care for problems that could be managed in primary care”. Our review included 44 studies conducted in 21 different countries. A thematic analysis of these studies identified the following five major themes over the period 2004 to 2024; accessibility and convenience; health anxiety; uncertainty and knowledge gaps in healthcare services available; external advice and encouragement; and personal influences.

Notably, despite 16 of the included studies having been published since 2020, we did not find that significant new themes arose in this period. This was somewhat surprising given the substantial disruption caused by the COVID-19 pandemic to healthcare systems [24]. Our thematic analysis resonates with the findings of a study conducted by Cummins et al exploring factors affecting ED utilisation before and during the pandemic [61]. This demonstrates the persistence of the underlying themes over time, and suggests their continued relevance before, during and after the pandemic period. Given that none of the studies included in our scoping review specifically investigated how the COVID-19 pandemic influenced patient motivation and urgent care-seeking at the GP—Emergency Care System interface, this may represent a valuable direction for future research. Interestingly, only three of the included studies incorporated the perspectives of healthcare staff [10, 35, 57]. While the patient perspective is clearly of prime importance, it may be that further research considering staff perspectives, such as paramedics, ED staff and GPs, may also be of value. For instance, knowledge gaps resulting from inefficient communication and the consequences of inefficient care pathways might not be evident from patient perspectives alone.

Ireland's first study to explore perceptions of healthcare providers towards the appropriateness of ED attenders, conducted by Breen and McCann, revealed a lack of clear consensus between professionals regarding the definition of an “appropriate” ED visit [62]. Without a clear understanding of “appropriateness” amongst frontline healthcare professionals, systemic efforts to manage ED or ambulance service demand may be misaligned. Additionally, undifferentiated presentations may be challenging for the emergency care system to categorise initially. This may be compounded by an unclear understanding of symptoms, appropriate care pathways available, and a tendency towards risk-aversion behaviours driven by health anxiety and fear of poor health outcomes. A disparity between clinical and patient perceptions of urgency may lead to risk-averse decisions to attend the ED or call for ambulance service [20, 48]. Some patients wish to seek a second opinion from other healthcare professionals, possibly reflecting a lack of trust towards the initial care providers, which may drive users to bypass primary care and seek care from emergency settings [42, 54, 63]. Previous literature has highlighted that different emergency care settings may use different criteria to assess urgency levels. This brings further challenges in distinguishing between “appropriate” and “inappropriate” ED visits [12]. Even within the same healthcare system, defining a “nonurgent” or “inappropriate” visit can be complex [35]. As Kellermann and Martinez noted, the ED is more than a hospital department, it serves as a standard to measure the overall strength of a community's public health, primary care and hospital systems [64], hence, the ED can serve as a buffer for the failures of the broader health systems, thus prompting the wider application of and important need for this review.

As an overall summary, our thematic map demonstrates a set of complex international themes that drive lower acuity emergency care presentations (Fig. 4). These themes encompass both patient-level motivators (including health literacy, cultural norms, and beliefs) alongside health system factors (such as the accessibility and availability of primary care). This suggests that both patient and system-level factors, and indeed their interactions, need to be considered in addressing “primary care” emergency system presentations. Capp et al. described in a qualitative study how successful frameworks must address issues beyond logistical accessibility to foster trust in GPs and address patients’ true health needs, which are often functions of overlooked personal influences [63]. These findings resonate with our key themes, “personal influences” and “health anxiety”. Notably, there is substantial resonance between these themes and the proposed mechanisms underpinning “clinically unnecessary” use of emergency and urgent care that were developed by O’Cathain et al. using realist review methodology in 2020 [23]. The “external advice” theme may have specific importance in that it highlights that a proportion of patients who present to emergency care settings with conditions that may be considered more appropriately managed in primary care have, in fact, done so following advice or referral from a primary care clinician. This suggests either a primary and emergency care system mismatch, or the need for some level of care in an emergency care setting for a proportion of presentations labelled as suitable for GP management. Categorisation of a clinical problem as suitable for definitive primary care management is known not to be straightforward, and there may be disagreement on what service is required to manage such presentations safely and effectively. Ultimately, integration between primary and emergency care systems is likely to be important in developing appropriate clinical care pathways. Such pathways must not only meet patients’ needs but must also facilitate the sustainable functioning of both primary and emergency care systems.

In this scoping review, we sought to consider relevant studies from both emergency department and emergency ambulance service settings, as together these settings represent an emergency care system under increasing strain. For example, for Ireland's population of 5.15 million [65], there are approximately 1.5 million emergency department attendances, and 400 000 ambulance calls each year [66]. The estimated population of England is 53 million [67], and in March 2025, there were 2 389 064 attendances to EDs, making it the busiest March on record, an increase of 0.8% compared to March 2024 [68]. In the same timeframe in March 2025, 734 310 ambulance calls were answered, this averages out to about 26 225 calls per day. In the United States, the number of ED visits was approximately 139.8 million annually [69], and EMS agencies respond to more than 40 million calls for service combined each year [70]. Thus, both ED and EMS elements of the system experience a significant volume of activity in different parts of the world. However, in terms of the international literature, we found only four studies specifically considered the emergency ambulance setting [11, 19, 20, 30]. Thus, insights into the factors contributing to low acuity ambulance service presentations appear to represent a significant gap in the literature, warranting further research [19, 20, 22, 30].. While findings from studies focused on ED usage may be applicable to ambulance services, the included ambulance-specific studies highlighted some unique and important considerations. For instance, ambulance services could be perceived as the safest, fastest, and most reliable mode of transport to emergency care [19, 30]. There may also be a perception that patients will be given high priority upon arrival at the ED with ambulance transport compared to self-transport [19]. Additionally, unique external factors can influence ambulance utilisation, such as in circumstances where a third party, a close relative or a neighbour calls an ambulance on behalf of the patient and independent of the patient's own decision-making [19, 30].

Some commenters have suggested that the traditional comprehensiveness of primary care, including its acute care role, has been sacrificed to create capacity for an increased focus on preventive care that targets risk factors rather than treating symptoms [71–73]. Notably, Killeen et al. reported that GPs practising at rural health centres had a broader scope of practice, including the provision of acute care as measured by an individual scope of practice score [74], and that increased rurality was associated with broader scope of practice [75]. The narrowing of the scope of practice in urban settings may hinder efficient acute care, reinforcing findings from our thematic map. Researchers have also found that to provide all recommended interventions to all eligible patients, a total of 26.7 hours is needed per clinical workday, an impossible situation in practice [71, 76]. With over half of the time dedicated to preventive care in patients who may have low baseline risks, GPs have less capacity for other needs, including acute care presentations. In addition, shorter consultations and high patient volume reduce patients’ access to regular GPs and weaken continuity of care, revealing a mismatch between patient needs and health services provided [71]. We suggest that this shift in focus is likely to divert attention away from acute care, contributing to the five themes in our review, particularly “accessibility and convenience”. Hence, patients with acute care problems need an alternative place of care, turning to EDs, worsening overcrowding. Ultimately, patient-centred care remains the central goal of medical services, and work is required to establish an equilibrium between the different priorities.

Strengths and limitations

Although this scoping review has several strengths, including employing a robust methodological approach [26], it also has some limitations that warrant consideration when interpreting its findings. The scoping review methodology serves to provide a comprehensive overview of a body of literature, but does not include a detailed quality appraisal of the included studies or an assessment of risk of bias. While we developed and employed a comprehensive search strategy it is possible that some relevant articles were not included. We excluded studies whose sole focus was on paediatric emergency system presentations, and such studies may be relevant in terms of addressing key issues. Finally, eight articles unavailable in English were excluded, as only full-text articles published in the English language were considered, and this could have potentially resulted in the exclusion of relevant literature published in other languages. Despite these limitations, we have developed an updated thematic map based on a comprehensive scoping review.

Conclusion

Through an extensive thematic analysis of international studies spanning two decades, it is apparent that decisions to seek help from the emergency care system depend on a multifaceted range of factors, including perceptions of accessibility, anxiety, trust and external influences. The findings suggest key gaps in healthcare integration between primary and acute care, and in understanding between healthcare providers and acute care patients. Our thematic map can therefore serve as a research-driven framework for considering and addressing the reasons why patients seek emergency care for problems that could be managed in primary care across different jurisdictions.

Author contributions

Conceptualization: Ka Yan Alison Chao, Geoff McCombe, Walter Cullen, Yohei Okada, Gayathri Devi Nadarajan, Fahad Javaid Siddiqui, Marcus Eng Hock Ong, Tomás Barry. Methodology: Ka Yan Alison Chao, Walter Cullen, Yohei Okada, Gayathri Devi Nadarajan, Fahad Javaid Siddiqui, Marcus Eng Hock Ong, Tomás Barry. Formal Analysis and investigation: Ka Yan Alison Chao, Tomás Barry. Writing—Original Draft Preparation: Ka Yan Alison Chao, Tomás Barry. Writing—Review & Editing: Ka Yan Alison Chao, Geoff McCombe, Walter Cullen, Yohei Okada, Gayathri Devi Nadarajan, Fahad Javaid Siddiqui, Marcus Eng Hock Ong, Tomás Barry. Resources: Tomás Barry. Supervision: Tomás Barry.

Supplementary data

Supplementary data is available at Family Practice online.

Funding

TB acknowledges funding support from the Health Research Board Ireland (CSF-2020-006, ECSA-2024-002).

Data availability

The data underlying this article are available in the article in the Methods section, with a comprehensive final search strategy (Supplementary S1 PubMed search strategy). This final search strategy was then adapted to meet the specific requirements of different online databases.