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Why are people increasingly attending the emergency department? A study of the French healthcare system
  1. Helene Colineaux1,2,
  2. Fanny Pelissier3,
  3. Laure Pourcel3,
  4. Thierry Lang1,2,
  5. Michelle Kelly-Irving2,
  6. Olivier Azema3,
  7. Sandrine Charpentier2,4,
  8. Sebastien Lamy2
  1. 1 Epidemiology Department, Toulouse University Hospital, Toulouse, France
  2. 2 EQUITY Team, UMR1027, Toulouse University, UPS, Inserm, Toulouse, France, Toulouse, France
  3. 3 Regional Observatory of Emergency Medicine in the Midi-Pyrénées, (ORU-MiP), Toulouse, France
  4. 4 Emergency Department, Toulouse University Hospital, Toulouse, France
  1. Correspondence to Dr Helene Colineaux; ln.colineaux{at}


Objective It is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types.

Methods This observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients’ condition during ED visit was determined through the ‘Clinical Classification of Emergency’ score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures.

Results The 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes.

Discussion It appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.

  • access to care
  • emergency care systems, admission avoidance
  • emergency care systems, primary care
  • emergency department utilisation
  • epidemiology

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  • Contributors HC wrote the statistical analysis plan, cleaned and analysed the data, drafted, wrote and revised the paper. She is guarantor. FP and LP monitored data collection and revised the paper. TL, MK-H and SC initiated the collaborative project, revised the statistical analysis plan and revised the paper. OA initiated the collaborative project, monitored data collection and revised the paper. SL wrote the statistical analysis plan, analysed the data, drafted and revised the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval The Midi-Pyrénées ED Observatory database was declared to the French National Commission for Data Protection and Liberties (CNIL) under declaration no 761 633 (31/08/2001). The database was anonymous.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.