Table 2.

Study Design, Methods And Factors That Influenced Decision Making

Author & Year	Country	Aims & Rationale	Study Design, Data Collection & Analysis	Sampling Strategy	Non-clinical Factors influencing behaviour and/or decision making/ Preferences elicited
Barwise- Munro, Morgan & Turner, 2018	U. K	Explore reasons why children might be more likely to be admitted to hospital, in an emergency unscheduled manner, rather than be observed at home by their caregiver or primary care team	Qualitative, semi structured interviews, thematic analysis	Convenience Sampling	•Parental anxiety and differing perceptions of illness may influence the decision to admit by most referring clinicians. •Referring clinicians reported they often err on the side of caution: “If I was uncertain, then that means I am not happy to send them home, by definition” •Clinicians referred to their “Gut Instinct” when deciding to send a patient to be admitted •Doctors stated they were more likely to refer those of lower socio-economic status •Previous admission history would influence decision •Time of day: more likely to refer later in the day than in the morning •A small number referred to their own paediatric experience a lack of which would impact on their confidence in treating
Brousseau, D. et al., 2011	U.S.A	Understand parental decisions to seek care for their children and physician perceptions of parents’ decisions to seek non-urgent emergency-department care.	Qualitative, in-depth interviews, Grounded Theory	Purposive sample of parents triaged as non- urgent in hospital emergency department on preselected days and PCP’s of same children	•PCP’s stated parent’s perception of severity of illness justified a visit to ED •PCP’s reported that they prefer to trust the instinct of parents and accept the judgements of parents and refer to the ED rather than take a risk on the child’s health. If they were unable to see a child they would refer to the ED if the parent described the child as being in severe pain, “inconsolable” or “very irritable, regardless of whether or not medication was tried before the ED visit. “I would rather be wrong 100 times than make a mistake” •PCP’s referred patients to the ED for resources such as tests and treatments not available in primary care offices. Perceived need of sutures, laboratories, and nosebleed cauterization resulted in immediate referral. •PCP’s did not believe ED compromised continuity of care however some differed in what they considered appropriate urgent care centres; paediatricians tended towards paediatric urgent care centres, while family practitioners were happy to utilize any urgent care services.
Dale, J. et al., 1995	U.K.	Compared the process and outcome of ‘primary care’ consultations undertaken by senior house officers, registrars and general practitioners in an accident and emergency department	Prospective controlled intervention study, administrative data, statistical analysis	Physicians: vocationally trained GPs recruited with preference to those who had recently completed training and flexible availability. Patients: stratified random sample of those assessed at nurse triage in A&E dept. with problems that could be treated in a primary care setting.	Primary care consultations made by sessionally employed GP’s in the ED resulted in less utilization of investigative and specialist resources. This included reduced rates of investigations such as radiography, prescriptions of antibiotics and referrals to specialist and outpatient clinics.
Haimi, M. et al., 2018	Israel	Explored the experiences, attitudes, and challenges of the physicians in a Paediatric Telemedicine Service operated in Israel, and explored whether the doctors are using non-medical factors (not related to the medical problem), when making the clinical decisions in this setting and if so, to identify and describe these factors.	Qualitative, semi-structured interviews, thematic	Random sample of those who currently work at the telemedicine service, or worked there in the past five years	•Doctors reported a “moral conflict” between offering good service to parents, who may apply pressure for a referral to the ED in order to avoid incurring cost, and adherence to best medical guidelines •When deciding whether to refer to the ED, doctors drew on their impression of the parent’s health literacy. They reported considering the parent’s ability to understand and follow instructions and capability to adequately provide care and recognise a worsening condition. This was especially important when the patient was unfamiliar to them. •GP’s relied on intuition and “rule of thumb” protocols when diagnosing patients •Those doctors perceived to be of a lower socio-economic status - judged through place of residence, distance from medical centre and language used - were referred to the ED more often •Doctor’s also took into account the accessibility and opening hours of medical centres, and referred those living in isolated areas to the ED more frequently •Doctor’s reported referring more often on weekends (which fall FRI- SAT in Israel) especially Fridays •Doctors reported considering legal implications and a fear of lawsuits as an influence on their decision to refer or not
Kini,N.M & Strait, R., 1998	U.S.A	Evaluated the pattern and reasons for non-urgent use of the paediatric emergency department during regular office hours and why primary care physicians approved such visits	Prospective, cross -sectional observational study, administrative data, χ2 method	Patients triaged as nonurgent in a paediatric ED from June to November 1994 between 6.30 am Patients triaged as non- urgent in a paediatric ED	•PED visits were approved for different reasons before and after 3.30 pm. Before 3.30 pm, visits were most commonly approved for being medically urgent. After 3.30 pm, the most frequent reason was full office schedule. •Physicians were more likely to deny a visit to the PED earlier in the day; 24/40 denials occurred before noon while 56/151 of approvals occurred before noon. •Approvals were more likely for patients who were younger, particularly 2 yrs. old or less, and for those presenting with fever or trauma.
Orimadegun, A.E. et al., 2008	Nigeria	Evaluated the quality of the contents of referral letters received at the paediatric emergency unit of the University College Hospital, Ibadan, Nigeria.	Prospective descriptive study, descriptive statistics	All referral letters were examined using a structured questionnaire.	•A worsening condition was the most frequently stated reason (17.8%) for writing a referral letter •Lack of funds to continue treatment (17.1%), lack of facilities (14.5%) and lack of expertise (10.4%) were all cited as reasons for referrals •15.8% of referrals were due to a parents’ request (15.8%)
Rhodes, K. et al., 2012	U.S.A	Explored factors, including the role of ED referrals, associated with specialists’ willingness to accept patients covered by Medicaid and the Children’s Health Insurance Program (CHIP)	Qualitative, semi-structured interviews, Qualitative iterative coding	Purposive sampling of physicians from across specialty areas that research suggested were in high demand, short supply, or both. Identified through combination of medical provider referrals (using a snowball technique) and the state licensure	Primary Care Physicians stated they used the ED as a “middle man” in order to ensure publicly insured (Medicaid) patients get access to outpatient specialty care and refer them to the ED to facilitate their access to specialists