Original Contributions
Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient’s perspective

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Abstract

Much has been written about “abuse” and “overutilization” of Emergency Departments (EDs). We undertook to study, from the patient’s perspective, physician and patient factors that influence the patient’s decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. In our study group of 948, most ambulatory patients (93%) seeking care in an ED have a primary care physician. From the patient’s perspective, most (76%) primary care physicians are not educating their patients about which situations warrant ED care and up to 54% are not informing their patients about which services are offered in the office. As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.

Introduction

Emergency Department (ED) utilization is an ongoing concern in Canada and the United States (U.S.). With economic constraints, Canada’s health care system has been driven to restructure. Over the last decade, provincial governments have forced the closure or merger of acute care facilities (1). There have been many recommendations to transfer care from the ED back into the hands of primary care providers or other community-based resources (2).

Concern has been expressed about the financial implications of the use of EDs for non-urgent care (2). Many articles have been written regarding the use of the ED for minor illnesses and injuries 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14. Steinmetz et al. in 1978 (15) showed that in Canada the use of the ED had increased since the implementation of universal health care. Statistics Canada, 1992 and Weil et al. in 1993 have shown that the annual rate of ED visits is higher in Canada than in the U.S. and continues to rise, despite the availability of alternative and fully insured health care 16, 17. Other studies show that more than one-third of all visits to EDs are non-urgent 18, 19, 20, 21, 22.

Identifying the cause of non-urgent use of the ED is a difficult task. Several studies point to primary-care access and availability as an important contributor 23, 24, 25, 26, 27. Other studies state that simply providing patients with a regular source of care does not greatly reduce the utilization of EDs for non-urgent problems 28, 29, 30, 31. Still others focus on the demographic variables of the patients who seek ED care 9, 18, 32, 33, 34, 35, 36, 37. The use of an ED may be the product of a decision-making process that is complex and influenced by many variables, including the patients’ perception of their illness or injury and their understanding of a universal health care system. Although most studies that have focused on urgency have had it “defined” or “perceived” by health-care professionals, it is ultimately the patient’s perception that influences the decision to seek care in an ED; these are two perceptions that differ in many ways. Traditionally, “inappropriate” use of an ED has been attributed to a failure of the primary care provider (PCP) to provide accessible services 23, 24, or to the patients’ understanding of how to use Emergency services 38, 39.

This study was designed to ascertain why patients come to the ED, and more specifically, how the physician–patient relationship affects the patient’s decision about when to seek Emergency Department care.

Section snippets

Methods

A convenience cohort, multi-center survey was conducted over a 2-day period, June 2 to June 3, 1997, from 8 a.m. to midnight. A questionnaire (see Fig. 1) was offered to all ambulatory patients (not brought in by ambulance) and was distributed by the registration staff or triage nurse. Patients who were triaged to immediately see a physician were not given a questionnaire. These exclusion criteria were designed to limit the study population to patients who could, potentially, have been seen in

Results

Statistical analysis was performed using univariate descriptive analysis. The mean, mode, standard deviation, and confidence intervals (CI) were calculated for each variable measured.

A total of 1,246 questionnaires were completed, and 298 were excluded, resulting in a study group of 948. Exclusion criteria included patients under 16 years old, visitors from out of the city, and incomplete surveys. Eight hundred and seventy-four (93%) patients had a PCP, of whom 839 (96%) were Family Physicians

Discussion

This study was undertaken to annotate, from the patient’s perspective, why patients choose to seek care in Emergency Departments in a major Canadian city. The patient–physician relationship was found to have a strong impact on the patients’ perception of their illness and the non-urgent use of the ED.

Some authors suggest that ED physicians are finding that the bulk of their workload involves treating non-urgent patients who they think could have been handled by a PCP (40). In 1990, one in five

Conclusion

Primary care physicians should play a stronger role in educating and counseling patients about the utilization of emergency care and the services offered in the office setting. We propose that changing patients’ perceptions of urgency and educating them about other appropriate services might reduce the use of the ED for many non-urgent reasons. From this study we identified several other reasons that might influence patients’ decision to present to an ED, such as the patient’s knowledge of

Acknowledgements

We acknowledge the staff at the following hospitals: Toronto General and Western Hospitals, Queensway General Hospital, St. Joseph General Hospital, St. Michael’s Hospital, North Western Hospital, Toronto East General Hospital, Missisauga General Hospital, Credit Valley Hospital, Markham Stouffville Hospital, York County Hospital, Oshawa General Hospital.

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