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Table 4 Included studies with description of method, number of included patients and results

From: Motives for self-referral to the emergency department: a systematic review of the literature

Article Method Number of patients Reasons for self-referral
 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
(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)
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
(147 self-referred patients)
Only adults?
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
(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
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
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
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
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
(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
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
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)
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
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
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.
 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
 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
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
 Rassin et al. [39] Isreal 2005 Questionnaire Multiple choice, multiple answers possible 73
Age > 18 years
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).