Factors associated with non-urgent utilization of Accident and Emergency services: a case-control study in Hong Kong

Abstract

Accident and Emergency Departments (A&E) have been a popular source of primary care, and studies have shown that up to two thirds of patients attending A&E have problems that could be managed by general practitioners (GPs). Although many studies have found that patients of lower socio-economic class with less social support have a higher utilization rate of A&E, some recent studies have revealed contrary evidence. In this study 2410 patients were randomly selected from four A&E at different times. The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. Two emergency physicians reviewed each case independently, and if their independent ratings were in agreement, this became the gold standard. Patients classified as GP cases were given a telephone interview, and a sample was selected and matched with cases from general out patient clinics (GOPC) in the public sector by morbidity. Reasons for not attending a private GP included closure of clinic, deterioration of symptoms, GPs’ inability to diagnose properly, and patients’ wish to continue medical treatment in the same hospital. Reasons why non-urgent patients did not choose to attend the nearby public GOPC included affordability, closure of the GOPC, patients’ wish to continue treatment at the same hospital, GOPC too far away, no improvement shown after visits to GOPC doctors, and GOPC doctors’ inability to make proper diagnoses. The reasons for high level of utilization of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. Interim clinical services provided to those non-urgent cases by nursing practitioners or by GPs working in A&E could also facilitate discharge of patients to primary care facilities.

Introduction

The hospital Accident and Emergency Department (A&E) is meant to serve patients with immediate life threatening or critical conditions. Non-urgent utilization refers to inappropriate attendance at A&E by patients whose conditions are neither accidents nor emergencies and often require no specific hospital treatment. The significant increase of inappropriate A&E attendance is considered to be a serious threat to the health care system. Some studies have found that up to two thirds of patients who attend A&E have problems that could be managed appropriately by general practitioners (Myers, 1982, Green and Dale, 1992, Driscoll et al., 1987; Bowling, Isaacs, Armstorn, Roberts & Elliott, 1987a; Bowling et al., 1987, Bowling et al., 1987b, Bentzen et al., 1987, Andersen and Gaudry, 1984, Dale, 1992, Cohen, 1987, Davies, 1986, National Centre for Health Statistics (McGraig LF), 1994, American College of Emergency Physicians, 1990).

In Shatin, Hong Kong (a satellite town with population of 500,000), a study has shown that over 20% of A&E consultations sought by elderly patients were not urgently needed (CUHK, 1994). Another local study illustrated that 50% of A&E attendees were non-trauma conditions (Leicester et al., 1991). Despite an education effort by the Hospital Authority, which oversees all the public hospitals in Hong Kong, the number of A&E attendees has escalated in recent years. Unlike some other countries, the triage of patients from emergency departments to primary care is considered inappropriate and impracticable in the present Hong Kong situation. Therefore, the authors have conducted a study to determine the level of inappropriate use, the nature of the morbidity pattern, the validity of the nurse triage system and the reasons why alternate and appropriate primary care services are not being accessed within this local context. This paper will report the factors associated with inappropriate utilization of A&E services in Hong Kong.