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

Background In several western countries patients’ use of Emergency Departments (EDs) is increasing. A substantial number of patients is self-referred, but does not need emergency care. In order to have more influence on unnecessary self-referral, it is essential to know why patients visit the ED without referral. The goal of this systematic review therefore is to explore what motivates self-referred patients in those countries to visit the ED. Methods Recommendations from the PRISMA were used to search and analyze the literature. The following databases; PUBMED, MEDLINE, EMBASE, CINAHL and Cochrane Library, were systematically searched from inception up to the first of February 2015. The reference lists of the included articles were screened for additional relevant articles. All studies that reported on the motives of self-referred patients to visit an ED were selected. The reasons for self-referral were categorized into seven main themes: health concerns, expected investigations; convenience of the ED; lesser accessibility of primary care; no confidence in general practitioner/primary care; advice from others and financial considerations. A random-effects meta-analysis was performed. Results Thirty publications were identified from the literature studied. The most reported themes for self-referral were ‘health concerns’ and ‘expected investigations’: 36% (95% Confidence Interval 23–50%) and 35% (95% CI 20-51%) respectively. Financial considerations most often played a role in the United States with a reported percentage of 33% versus 4% in other countries (p < 0.001). Conclusions Worldwide, the most important reasons to self-refer to an ED are health concerns and expected investigations. Financial considerations mainly play a role in the United States.


Background
The utilization of Emergency Departments (EDs) is increasing in several high-income countries [1,2]. Inappropriate presentations to EDs are a burden for healthcare systems, contributing to excess diagnostics and treatment, overcrowding of EDs and longer waiting times; all are associated with increasing health care costs [3][4][5]. This is important, because worldwide health care expenditures as a share of gross domestic product are increasing over the last years [6]. In addition, using the ED for primary care problems reduces continuity of care for patients.
Several countries experience high percentages of self-referred ED-patients. In England, 62.8% of EDpatients is self-referred [1]. In the United States (USA), relatively few general practitioners (GPs) are available and patients often self-refer to EDs or other types of specialized care [7]. In the Netherlands, despite its strong primary care network, 30% of ED-patients is self-referred [8]. Within the category of self-referred patients is a substantial number of patients that could have been taken care of in primary care. In a previous study, our group found that between 41.2 to 51.9% of self-referred patients in a Dutch ED visited the ED inappropriately [9]. This is crucial, because strategies that aim to reduce ED utilization should target inappropriate self-referral. In order to reduce inappropriate self-referral, it is essential to know why patients visit the ED directly. The goal of this systematic review is to explore what motivates self-referred patients worldwide to visit the ED directly.

Methods
Recommendations from the Preferred Reporting Items in Systematic Reviews and Meta-Analysis (PRISMA) were followed [10].

Search strategy and data sources
The following five databases: PUBMED, MEDLINE, EMBASE, CINAHL and Cochrane Library, were systematically searched from inception up to the first of February 2015. Searches were conducted using a combination of the following search terms: emergency department, self-referred, referral, walk-in, motives and reasons with appropriate wildcards and variations in spelling. The search in Pubmed was as follows: ("Emergency Service, Hospital" [Mesh] OR "emergency department" OR "emergency room" OR "emergency unit" OR "emergency service" OR "emergency ward") AND (self-refer* OR refer* OR walkin*) AND (motiv* OR reason*), no limits were used. A similar search was conducted for the other databases.
The reference lists of the included articles were screened for additional relevant articles.

Inclusion criteria
Inclusion criteria were: study participants were selfreferred patients in the ED (not referred by a GP and not brought in by ambulance), the study reported on reasons for patients to visit the ED without referral. All age groups and all disease categories were included. Different methods to study these motives were accepted. Only articles in English and Dutch language were included.

Data extraction
Two authors (NK and HL) independently and in duplicate reviewed the titles and abstracts of retrieved publications and subsequently the full text was reviewed for possibly relevant articles. From the included articles, data on study purpose, design, setting, sample size, patient characteristics, study quality and country where the study was conducted was extracted. Disagreements were resolved by discussion until consensus was reached. The PRISMA flow diagram is shown in Fig. 1.
All different reasons for self-referral that were reported in the studies were listed. From these lists, seven themes for reasons for self-referral were identified by the study group (expert opinion) and consensus was reached within our group. Subsequently, the different reasons for self-referral that were found in the included articles were categorized into the seven themes. The themes were: health concerns; expecting investigations; convenience of the ED; lesser accessibility of primary care; no confidence in GP/primary care; advice from others; financial considerations (Appendix 1, 2).

Statistical analysis
A random-effects meta-analysis was used in which all eligible studies were included. The meta-analysis was performed using the inverse variance method, with an empirical Bayes estimator for the heterogeneity parameter tau 2 , a Hartung-Knapp adjustment, and an arcsine transformation of proportions. Results of the primary studies were reported with Clopper-Pearson exact confidence intervals. The software R, version 4.1-0, package meta, from Guido Schwarzer (2015) was used [11].
In order to investigate whether the differences in reasons for self-referral could be explained by different healthcare systems or different study methods, the following subgroup analyses were performed: reporting on a specific condition; continent; including multiple choice questions; possibility to select multiple answers with multiple choice questions; including a Likert Scale; the year in which studies were published in; inclusion of only patients with non-urgent medical problems; and included age group (children, adults, all ages).

Reasons for self-referral
Various motives for self-referral were found, with overlapping motives between studies. Percentages of the reasons reported by different studies were divergent. The reasons for self-referral were categorized into seven themes: health concerns; expecting investigations; convenience of the ED; lesser accessibility of primary care; no confidence in GP/primary care; advice from others; financial considerations. The different themes with examples are shown in Table 2.
To find the most common reasons for self-referral, a meta-analysis was performed; the results are shown in Table 3.
Both the year in which a study was published and the use of a Likert scale had a small influence on the heterogeneity regarding health concerns; reflected by an I 2 remaining higher than 97%.
Thirty-five percent of the self-referred patients visited the ED because they expected to need laboratory or radiological investigations. The studies reporting on this reason for self-referral were all conducted in either Europe [3, 5, 12, 13, 15, 21-23, 26, 28] or Australia [37,38].
'Convenience of the ED' was reported by 18% (PI 0-62%) of self-referred patients. There were no subgroups with a significant relation to this theme.
The theme 'accessibility GP' was indicated by 13% (PI 0-36%) of self-referred patients. Multiple studies found patients claiming their GP is not available or not having a personal GP [3, 5, 12, 13, 17, 20-26, 29, 32, 35]. Several studies found patients declaring they did not think of their GP, were not aware of other services, such as a walk-in clinic or GPcooperative, or did not know the location of an alternative service [5,11,12,21,22,32]. Also within this theme, several studies found that patients turned to the ED, because they felt they had to wait too long for an appointment with their GP [5,17,23,25,28,32] No statistically significant differences were found in subgroup analyses.
Lack of confidence in their GP was reported by 5% (PI 0-40%). Only studies from the UK [16,24,25] and the Netherlands [6,13] reported on this reason for self-referral.
For none of the themes, the variation in the percentages could be explained by the use of multiple choice questions (with or without multiple possible answers) or the inclusion of only patients with a specific condition.

Discussion
EDs are designed to provide emergency care and are not ideal locations for primary care, because there is no continuity of care, there is a risk for unnecessary testing and an ED-visit is more costly than a primary care visit [40]. This review shows that health concerns and the expectation to need further investigations are the most frequently reported motives to visit an ED without referral. Both motives reflect patients worried about their health, seeking urgent medical care. This is remarkable, because sixteen out of thirty of the selected studies only included patients with non-urgent problems. Patients may often be unable to judge the severity of their condition and may view non-urgent symptoms as urgent.
These two most common motives are difficult to address; there will always be differences between self-assessed and clinically assessed urgency and patients can only be expected to act on their own perceptions. Awareness programs that have been studied showed a limited effect. In one study, performed in the USA, people received a booklet with general information on when to visit an ED, but this did not show a significant effect on the number of ED-visits [41]. Education directed at specific conditions (ear pain in children, diabetes, asthma) and more intensive programs for geriatric or older, chronically ill patients have shown mixed results [42][43][44][45][46][47]. The effect of telephone consultation for patients to call for advice about their current health symptoms prior to seeking treatment at the ED also seems insufficient.
In 1998, the UK introduced NHS Direct; a national nurse-led telephone advice service. Data suggested that this service reduced the number of calls to GPcooperatives, but did not have a significant impact on the number of ED-visits [48]. Since 2014, NHS Direct has been replaced by NHS 111 with better integration with other health services. However, also NHS 111 has failed to reduce the number of ED-visits [49]. In the Netherlands, the implementation of ECAPs, a system where patients who unnecessarily visit the ED can be triaged to GPs, showed promising results in decreasing ED-utilization [50]. Health care systems are different between countries. The largest differences consist of how primary care is organized and the charges patients face when consulting a GP or ED. The results of this review should therefore be interpreted in the context of these health care systems.

Health care system
Most European studies were performed in the UK and the Netherlands. These countries have similar health care systems, which heavily rely on primary care and most patients have a personal GP. During out-of-office hours patients can visit GP-cooperatives or walk-in clinics to get primary care. GPs are supposed to act as gatekeepers to secondary or specialist care, but patients can attend the ED without a referral if their condition, in their opinion, seems sufficiently urgent to them. In the Netherlands, people have a deductible excess charge of € 385 a year (in 2016); the first € 385 of medical bills, including the costs of an ED-visit, are charged to the patient. In contrast, emergency care is free of charge in the UK. GP-care is free of charge in both countries [51][52][53].
Despite the well-developed primary care systems, both countries have substantial numbers of self-referred The two studies originating from the United States, reporting on financial considerations as a reason for self-referring to the ED, found significantly higher percentages of self-referred patients visiting the ED for this reason than studies from other continents did ED-visits. Hospital Episode Statistics reported that in 2012-13, 64.1% of ED-visits (also including visits to minor injury units and walk-in centres) in England were self-referred [54]. In the Netherlands, 30% of ED-patients were self-referred in 2012 [8]. It has been shown that many of these patients visit the ED inappropriately [9,52]. At the same time, ED crowding and ED waiting times are increasing, which underlines the importance of reducing the number of inappropriate self-referred patients [8,55,56].

Study findings
European studies found that patients reported visiting the ED because they expected that they needed laboratory or radiological investigations. Patients cannot get the same level of care with their GP and they visit an ED, when they expect that more advanced care will be necessary. A well-established primary care system does not change this.
Only studies from the UK and the Netherlands, reported a lack of confidence in their GP as a reason for self-referral to an ED, albeit with a low percentage. However, this is probably merely a reflection of the strong primary care network.

Practice implications
In the Netherlands, recent years an increasing number of EDs and GP-cooperatives are collaborating by creating Emergency Care Access Points (ECAPs) to reduce the number of self-referred ED-visits. During out-of-office hours, patients register at a conjoint desk, from where they are triaged to be seen by a GP or at the ED. This system shows promising results and is associated with an overall decrease in the number of ED-visits, almost disappearance of selfreferred patients and a higher probability of hospital admission [50].

Health care system
The health care system of the USA, developed largely through the private sector, and combines high levels of funding with a low level of government involvement [57]. It has a small proportion of GPs and relies heavily on internal medicine and pediatrics for primary care [7]. In addition, the USA used to have a large proportion of uninsured or underinsured patients and patients often faced high cost sharing, including deductibles for primary care [57]. Because EDs are the only place where the poor could not be turned away, EDs were disproportionally used by low-income and uninsured patients who could not afford care in other settings [58]. In an attempt to deter inappropriate visits from EDs, several states implemented co-payments for non-emergency visits.
Recently, the health care system in the USA has undergone several changes, with the implementation of the Patient Protection and Affordable Care Act (PPACA) since 2010. With PPACA the percentage of uninsured patients is declining [59]. In addition, the funding for health centers was increased, which deliver preventive and primary health care to patients, regardless of their ability to pay. Between 2007-2015 these health centers have increased the number of patients served from 16 million, to 24 million annually [60].
Despite these measures, it seems that the number of ED-visits is still increasing: from 95 million in 1997, to 130 million in 2010 [61,62]. In 2015, the American College of Emergency Physicians (ACEP) found that the majority of emergency physicians have noticed an increase in the volume of emergency patients since the requirement to have health coverage took effect in the PPACA in 2014 [63]. In addition, the number of EDs has decreased over the last years. Together, this leads to more overcrowded EDs [64].

Study findings
Studies from the USA reported significantly more frequently on issues with health-insurance and costs. This is to be expected, considering the charges patients faced when seeking medical care. However, all included studies were performed before the implementation of the PPACA, so it is not clear whether this affects the motivation of patients to visit the ED.

Practice implications
New research is necessary to see whether the motives for self-referral have changed since the PPACA was introduced.

Health care system
Australia has a complex health care system, with public and private funders and providers; including public and private hospitals with EDs. Medicare, the tax-funded national health insurance scheme, offers patients free, self-referred access to the ED. GPs act as gatekeepers to the rest of the health care system, since patients need a GP-referral to consult a specialist [65].
It is estimated that the number of public ED-visits increased by 3.4% on average each year between 2010 and 2015. In 2014-15 there were about 7.4 million EDconsultations in public hospitals; 75% of patients who visited the ED had an arrival mode of 'Other'; meaning they walked in or came by private or public transport, community transport or taxi. Ten percent were triaged as non-urgent [66].

Study findings
Studies from Australia found the highest percentage of patients visiting the ED out of health concerns and with the expectation to need investigations. There is no clear explanation for this finding.

Practice implications
Both motives are difficult to address.

Overall
Studies have shown that a strong primary care network may help to reduce the number of self-referred patients in the ED, especially when patients have access to a GP for immediate care [67]. In our study, 13% of self-referred patients visited the ED because of the limited accessibility of primary care. So, better organization of primary care, with fast and easy access, might reduce the relatively small, but substantial number of patients self-referring to for this reason. Remarkably, we found no difference between continents in the percentage of the theme 'accessibility of the GP' was reported, despite the varying accessibility of primary care in the different healthcare systems. This might be because this theme reflects patients not getting a timely appointment with their GP in one country versus not having a personal GP in another country. Despite the wellestablished primary care in Europe and Australia, the number of non-urgent patients in EDs is substantial. This may be caused by the fact that the countries that have well established primary care systems also have well established healthcare insurance systems and historically have low thresholds for seeking medical consultation.
The results of this study show that health concerns are a major motivation for patients to selfrefer to the ED, including for patients with nonurgent symptoms. This might be an important explanation for the limited effects of previous interventions; people who are worried about their health, will not be easily discouraged in seeking help at the ED. A solution in which a medical professional can triage self-referred patients to either a GP or the ED could relieve the patient of the burden of choosing the appropriate facility to present to, without discouraging patients to seek urgent medical care if needed. We believe the introduction of ECAPs may be that solution; the data on the effectiveness of ECAPs is promising, but is limited and subject to future research of our group.

Strengths and limitations
Strength of this study is that it reviews motives from self-referred patients worldwide, which provides data on what motives patients have to seek urgent medical care in EDs. These data can be used by policymakers to adjust healthcare systems in order to decrease selfreferral associated costs. In addition, this study interprets the results of this review by taking into account the differences of healthcare systems in which the studies were performed.
This study only includes studies in Dutch and English and might therefore have missed some relevant articles.
Seven articles used multiple choice questions, with the option of selecting multiple answers [12,13,15,16,33,37,39]. Unfortunately, it is not clear from these articles how many patients selected multiple answers. This makes it impossible to assess what reasons were most important for these patients in selfreferring to the ED.
This review could not explore whether motives for appropriate and inappropriate visits differ, because the included studies did not report on the appropriateness of ED-visits.
Large variations in reported percentages of reasons for self-referral between studies were found, reflected by wide prediction intervals and high levels of heterogeneity. Subgroup analyses were performed in order to analyze whether this could be explained by different healthcare systems or study methods, but not all heterogeneity could be explained. It is plausible that other, unknown factors that are not reported in the original manuscripts influence the reported percentages and the inability to explain reporting heterogeneity might therefore be.

Conclusion
Reasons for self-referral to EDs differ slightly with different healthcare systems. Worldwide, the most important reasons to self-refer to an ED are health concerns and additional investigations. Financial considerations mainly play a role in the United States. 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. [  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. Table 4 Included studies with description of method, number of included patients and results

(Continued)
Rieffe et al. [17] the Netherlands 1999 Questionnaires, Likert scale 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.  -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     Table 5 Reasons for self-referral categorized in themes (Continued) [5] Jaarsma van Leeuwen The Netherlands 1068