Table 4.

Included studies with description of method, number of included patients and results

Article	Method	Number of patients	Reasons for self-referral
Europe
Mestitz [28] United Kingdom 1957	Questions asked by casualty medical officer	975 (770 self-referred patients) Only adults? Only medical patients	The commonest reply was that it was more convenient to come to the hospital than go to the surgery. A few were genuinely surprised when I told them that the proper course was to consult their own practitioner first. This leaves those patients -quite a considerable number- who, without admitting that they did not trust their own doctor, indicated that they thought that better treatment would be meted out to them in hospital. The two chief factors in this group were the feeling that x-ray examinations were more readily ordered in hospital, and that a hospital doctor would carry out a more thorough examination. Mothers who brought their children often gave this last answer.
Wilkinson et al. [24] United Kingdom 1977	Interviews, using questionnaires	546 (213 first attenders registered with a GP near enough to visit and who had neither come by ambulance nor been sent in to see a doctor immediately by the casualty receptionists for emergency treatment) All ages Exclusion: emergency admissions, suffering from alcohol or addictive drugs	14% Needs hospital treatment 17% Considered urgent 1% Previous patient at hospital 14% Hospital more convenient 2% GP too far away 4% Did not want to lose work time 14% GP away or not available 5% Did not wish to wait for GP appointment 11% Sent by someone (usually employer) 2% Dissatisfied with GP 9% Other reasons 7% Don’t know
Myers et al. [26] United Kingdom 1982	Question asked	150 Only adults? Exclusion: collapse, abdominal and chest pains, acute gynecological problems, overdose and major medical problems	Problem thought to need hospital tests or treatment 71 (47%) Could not wait for GP appointment 32 (21%) Referred to hospital by employer, nurse, etc. 13 (9%) Miscellaneous (e.g. hospital nearer, is open all night, dislike of GP, don’t know) 19 (13%) Requesting second opinion 7 (5%) Happened to be in hospital anyway 3 (2%) Does not have GP 5 (3%)
Singh [21] United Kingdom 1988	Interviews, using semi-structured questionnaire	217 All ages	Eighty nine patients cited urgency as afactor in their decision to bypass the general practitioner and go direct to the casualty department. Fifty three patients thought that they would need an x rayexamination and gave this as the reason for self-referral. Thirty nine patients thought that their doctor was not available after surgery hours and 16 that it would be quicker going to the casualty department. Other responses included advice from friends and relatives (15 patients) and being out of the practice area at the time of the emergency (14). Twelve patients specifically cited not wanting to bother their doctor as their reason for attendance.
O’Halloran et al. [16] United Kingdom 1989	Questionnaires Multiple choice, multiple answers possible	145 (124 self-referred patients) Age: 18 months to 16 years. Visited with acute asthma, at least one more visit in the preceding 12 months.	40% GP said to go to the hospital if child bad / have always been sent to AED so now go straight here 30% Quicker to go to AED than to wait for GP or locum to visit 29% Nebuliser only thing that helps 21% Little confidence in GP 11% Better facilities for treatment in hospital 10% No point calling GP because he can’t do anything parents haven’t done already 7% Feel safer in hospital 6% Told to come by hospital staff 4% Have nebulizer at home and need to go if that fails 9% Other reasons
Stewart et al. [18] United Kingdom 1989	Questionnaires	853 (585 self-referred patients) Children	20.9% Anticipated referral 16.2% Better treatment at hospital 11.5% Always come to hospital 6.5% Wanted second opinion 10.3% Hospital more convenient 9.6% Too long wait for family doctor 5.6% Too difficult to contact family doctor 4.3% Hospital always open 5.9% Did not want deputizing bureau doctor 7.5% Patient attending for this condition 0.7% Patient attending hospital for other condition 1.2% Missing information
Thomson et al. [19] United Kingdom 1995	Questionnaires Multiple choice	245 (147 self-referred patients) Only adults? Non-emergency	15% Easier geographical access 24% Convenience related to timing 59% GP’s perceived inability to treat disorder 3% Other
Ward et al. [25] United Kingdom 1996	Question asked by treating physician	970 All ages Primary care problem	Question answered by 339 patients: Problem not appropriate for GP 92 (27,1%) Not convenient to see GP 76 (22,4%) Advised by health professional 39 (11,5%) (health professional not specified, not the GP) Second opinion 33 (9,7%) Did not try to see GP 33 (9,7%) Appointment not available with GP 25 (7,4%) Unable to contact GP 21 (6,2%) Dissatisfied with GP 15 (4,4%) Other 5 (1,5%)
Laffoy et al. [15] Ireland 1997	Interviewer-administered questionnaires Multiple choice, multiple answers possible	557 (395 self-referred patients) All ages	35.4% Thought I needed immediate attention 18.2% Thought I needed an X-ray 13.7% Hospital is convenient 7.6% Thought GP would refer me anyway 7.1% I prefer hospital for this condition 5.6% I’m under hospital care already 0.8% Hospital cheaper than GP 0.3% GP told me to go to A&E 14.4% Other
Shipman et al. [23] United Kingdom 1997	Telephone interviews, semi-structured	82 All ages	When the patient had not attempted to contact their GP or deputizing service prior to attending A&E, reasons included seeing A&E as the appropriate service for a particular problem, in particular when the problem started suddenly and A&E was seen as having the most appropriate diagnostic service. For some A&E attendees, decision making appeared to be have been less related to perceptions of appropriateness than to service availability. In some cases it was assumed that there was no out-of-hours general medical service available. For other respondents, A&E was seen as the speediest option for seeing a doctor.
Rieffe et al. [17] the Netherlands 1999	Questionnaires, Likert scale	430 Only adults? ‘Could have been seen by a GP’ Exclusion: too confused or in too much pain to complete questionnaire	Profiles of two major patient groups could be identified. One group comprised patients with a high socio-economic status living in suburbs, whose motives for visiting the ED are mainly of a financial nature. Patients in the second group mainly lived in the inner city and preferred the expertise and facilities provided by the ED.
Jaarsma-van Leeuwen et al. [5] the Netherlands 2000	Questionnaires Multiple choice	1068 All ages. Only surgical patients	6.1% own GP not in area 2.6% no trust in GP 47.7% not thought of GP 11.4% did not want to wait for an appointment with a GP 28.3% wanted specialist care (eg radiologic investigations) 3.9% otherwise (treated in the hospital, working in the hospital, no personal GP, could not reach GP)
Rajpar et al. [22] United Kingdom 2000	Interviews, using semi-structured questionnaire Multiple choice	54 All ages ‘Primary care problem’	50% ‘GP was closed’ 3.7% tried to contact GP 22.2% Perceived severity of problem 11.1% Did not want to disturb GP 7.4% Wanted second opinion 5.6% Perceive wait at A&E shorter than at GP cooperative 3.7% Perceived that facilities and investigations better at A&E
Coleman et al. [12] United Kingdom 2001	Questionnaires Multiple choice, multiple answers possible	255 Adults Patients with ‘low priority for treatment’	38% Availability of other services 62% Awareness of other services 11% Patient preference 70% Positive experiences of A&E 56% Processes and patient’s time 24% Convenience of access 76% Perceptions of seriousness 38% Seeking assurance 43% Other directed 68% Seeking particular services (all subdivided into smaller categories)
Norredam et al. [27] Denmark 2007	Questionnaire Multiple choice	2746 Age > 14 years Ambulatory patients	13% I could not get in contact with a GP 63% The ER is most relevant to my need (24% I was referred by a primary caregiver)
Moll van Charante et al. [3] the Netherlands 2008	Postal questionnaires Multiple choice	808 (224 self-referred patients) All ages	36% Further research (eg X-rays) was necessary 30% The doctor in the AED is best qualified for this problem 16% The AED is better accessible than the GP cooperative 5% It was related to a recent hospital contact or procedure 4% I didn’t want to disturb the GP / no GP available 5% Other 4% Missing
Mc Guigan et al. [14] United Kingdom 2010	Interviews by telephone, semi-structured	196 Age > 16 years Exclusion: patients who were seriously ill or otherwise vulnerable	48% Perceived appropriateness of condition 35% After taking advice from others 3% Anticipation of referral by GP 6% Accessibility of ED 5% Unavailability of GP 1% Other
van der Linden et al. [20] the Netherlands 2014	Open question by triage nurse	3028 All ages	1751 self-referred patients answered the question (58%): 34% Accessibility and convenience 27% Perceived medical necessity (Less often, no percentages given: Not thought about GP, Not having a regular GP, Familiarity, Dissatisfaction with GP, Referral by non-professionals)
de Valk et al. [13] the Netherlands 2014	Questionnaires Multiple choice, multiple answers possible	436 Age > 18 years Exclusion: patients who were unable to fill out the questionnaire	28% Patients’ assumption that medical care was needed that a GP cannot provide (eg. X-ray, blood tests) 17% Patient was already under specialist care at the study hospital 16% Patient could get help earlier at the ED 11% The ED was nearby 11% Patient was not registered with a GP 7% Patient could not reach the GP/GP-cooperative 5% The location of the GP-cooperative was unknown 4% Previous negative experience with the GP/GP-cooperative 3% Patient had no faith/trust in the GP 3% On the advice of others 2% Patient perceived the complaint was urgent
North America
Hunt et al. [33] USA 1996	Questionnaires Multiple choice, multiple answers possible	1547 All ages	Columbia Grand Strand Regional Medical Center (tourist community) (n = 548): 126 23.0% “I’m from out of town and just looked for the nearest emergency room.” 119 21.7% “Don’t have a doctor/clinic that regularly takes care of me.” 110 20.1% “Don’t have to make an appointment at the emergency room.” 86 15.7% “Better medical care here than other places.” 80 14.6% “My problem is bigger than my regular doctor/clinic could take care of.” 66 12.0% “My doctor/clinic told me to come to the emergency department when the office is closed.” Pitt County Memorial Hospital (training program): n = 990 responses 154 15.6% “Don’t have a doctor/clinic that regularly takes care of me.” 142 14.3% “Better medical care than other places.” 126 12.7% “Don’t have to make an appointment at the emergency room.” 109 11.0% “My doctor/clinic told me to come to the emergency department when the office is closed.” 75 7.6% “My doctor couldn’t see me soon enough.” 70 7.1% “My problem is bigger than my regular/clinic could take care of.”
Koziol-McLain et al. [34] USA 2000	Interviews, qualitative methodology	30 Age > 18 years (despite this inclusion criterion 1 patient of 17 years was included) Non-urgent	5 themes were found - Toughing it out - Symptoms overwhelming self-care measures - Calling a friend - Nowhere else to go - Convenience
Northington et al. [31] USA 2004	Questionnaires + brief interview	279 Age > 18 years Non-urgent	76.1% Better care 73.6% Urgency 68.6% Immediacy 41.9% Payment flexibility 39.7% Expediency
Howard et al. [30] USA 2005	Interviews, qualitative methodology	31 Age 18–50 years Non-urgent complaints	Three major themes: - They were unable to obtain an appointment with a PCP - They were referred by the staff (not the doctor) in PCP’s offices to be evaluated in the ED - It took less of their time to be seen in the ED than it did to contact their PCP, only to be told to go to the ED
Ragin et al. [32] USA 2005	Interviews, questionnaires. Likert scale	1536 Age > 18 years Not cognitively or medically impaired	Medical necessity was the most frequently cited reason (95.0%), followed by convenience (86.5%), ED preference (88.7%), affordability (25.2%), and limitations of insurance (14.9%).
Grant et al. [29] USA 2010	Interviews, qualitative methodology	112 Children Non-emergency	The majority of participants cited some aspect of clinic or pediatric office operations as the principal reason for coming to the ED. Other problems cited included clinic capacity, inconvenient appointment times and long waits for appointments. Several caregivers said they preferred to obtain care at the ED because they could be seen on a walk-in basis. Some parents reported problems getting their health coverage transferred after moving, and knew they could be seen without insurance at the ED. Also a frequently cited reason for the ED visit was the need for follow-up care.
Asia
Shah et al. [36] Kuwait 1996	Questionnaires, open ended question	1146 Only adults?	27.8% Hospital better or clinic worse/medicine not available 59.8% Accessibility/availability of ER 11.0% Have ‘wasta’ (connection or social intermediary) 14.0% Worker in hospital 7.5% Clinic closed or not available or do not know clinic timings 13.2% Hospitals close by or convenient 12.1% Have file, appointment, regular patient 2.0% Refused by PHC 10.7% Condition urgent 1.6% Other
Lee et al. [35] Hong Kong 2000	Telephone interviews, using questionnaires	2410 (726 patients with conditions that could be treated by GPs) All ages	For those patients who attended A&E with conditions that could be treated by GPs, main reasons were: 43.8% Perceived emergency status of their disease 28.9% Feeling sick on public holidays or at night 12.4% Living in close proximity to the hospitals 11.4% Availability of proper diagnosis and efficient service at the time of day it was needed 3.4% Low cost Other factors which also demonstrated statistical significance were the desperate need for help, the feeling that the situations could best be handled in the A&E facility, and the fact that patients had been sent to the department from school or from their workplace
Australia
Masso et al. [38] Australia 2007	Questionnaire, Likert scale	397 All ages ‘Primary care patients’, category 4 or 5 of the Australasian Triage Scale	67.3% My health problem required immediate attention 38.2% My health problem was too serious or complex to see a GP 15.4% I feel the medical treatment is better at the ED 5.7% I wanted a second opinion 1.6% Id did not want my GP to know about this health problem 3.4% I usually prefer to talk a doctor a don’t know about my health problems 51.3% I am able to see the doctor and have any tests or X-rays all done at the same place 7.6% I am not able to get in as a patients at GP surgery as the books are closed 12.6% I am not happy with the time I have to wait to get to an appointment with a GP 4.2% I do not like making appointments 8.4% It is easier for me to go to the ED 2.9% There is no charge to see a doctor at the ED 3.4% There is no charge for X-rays or medicine at the ED 0.5% I wanted to see a female doctor 0.8% Doctor or interpreter who speaks my language 1.3% Aboriginal health staff 1.3% Prefer ED environment 2.6% Traditional use by family
Siminski et al. [37] Australia 2008	Questionnaires Multiple choice, multiple answers possible	400 All ages Low urgency /acuity	Patients could choose multiple answers from 18 options. The most striking finding was the consistency of the most prevalently selected reasons across all age groups. Self-assessed urgency, access to diagnostics and self-assessed complexity were selected most often. 80% Problem too urgent 53% Problem too serious/complex 34% Medical treatment better at ED 14% Second opinion 2% Did not want the GP to know 6% Prefer doctor I don’t know 74% See doctor and have tests/x-rays done in same place 16% Not able to see GP as books are closed 24% Not happy with GP waiting time 12% Do not like making appointments 21% Easier to get to the ED 9% No charge to see a doctor 10% No charge for X-rays or medicine 2% Female doctor 2% Doctor or interpreter who speaks my language 2% Aboriginal health staff 5% Prefer ED environment 9% Traditional use by family
Others
Rassin et al. [39] Isreal 2005	Questionnaire Multiple choice, multiple answers possible	73 Age > 18 years Home-discharged	62.86% of the participants reported that they had decided to go to the ER since the quality of treatment there was higher compared to the community local clinic. 47.17% indicated that the geographical proximity of the ER to their residence had led them to turn to it for medical treatment. This reason was especially prominent (66.67%) among the 70 and older age group. 68.57% indicated that they had decided to visit the ER following a recommendation of a relative. Factors analysis using linear regression, conducted to examine what had most influenced the decision to go to ER, showed that relatives’ recommendation had an overwhelming affect (b = 0.333, P = 0.012).