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

Abstract

BackgroundIn 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.MethodsRecommendations 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.ResultsThirty 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).ConclusionsWorldwide, 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.

‘Clinically unnecessary’ use of emergency and urgent care: A realist review of patients' decision making

“…Some of the programme theories had been identified by the authors of the original reviews from which we drew our qualitative studies, although we were able to offer more understanding of how these issues affected people. In particular, uncertainty causing anxiety and the need to manage risk by getting reassurance; fear of consequences particularly around children and the bystanders' role in use of ambulances; stress and the need for low burden when seeking care in terms of social deprivation affecting ambulance use; compliance in terms of other people recommending or making the decision to contact a service, including service providers; consumer satisfaction in terms of positive views of emergency departments offering the expected investigations in a single place and negative views of general practice due to lack of confidence in GPs; and frustration around access to primary care . Some of our programme theories were also supported by research on general demand for emergency and urgent care.…”

“…In this instance, we developed our programme theories only using journal articles reporting qualitative research or qualitative components of mixed methods studies because these offered insights based on in‐depth exploration of patient perspectives. Because a number of substantive reviews had already been published or were ongoing (Turnbull et al https://www.southampton.ac.uk/healthsciences/research/projects/a-study-of-sense-making-strategies-and-help-seeking-behaviours.page), we searched for relevant papers included in these four reviews.…”

“…Coster et al had searched MEDLINE, Embase, Cochrane Library, Web of Science and CINAHL 1995‐2016. Kraaijvanger et al had searched MEDLINE, Embase, Cochrane Library, CINAHL and PubMed up to February 2015. Booker et al had searched MEDLINE, Embase, PsycINFO, Web of Science and CINAHL 1980 to June 2014.…”

“…A recent rapid review of qualitative, quantitative and mixed methods studies primarily from the United States and the United Kingdom identified six reasons for attendance at emergency and urgent care services: a lack of access to and confidence in primary care; perceptions of urgency or anxiety creating a need for reassurance from emergency services; recommendations to attend from friends or family or health‐care professionals; convenience in terms of services having better opening hours or being located closer to home than alternatives; patient factors such as lower cost than other options or lack of transport; and perceived need for treatment and investigations available at the hospital. Another recent systematic review, focusing more narrowly on reasons for self‐referral to emergency departments, identified a similar set of issues . A systematic review of use of ambulance services for primary care‐sensitive conditions included the perspectives of health professionals and service managers as well as patients .…”

“…Whilst these systematic reviews provide valuable high‐quality evidence related to this issue, there is a need for a more in‐depth understanding of what drives patients to seek care urgently when it is clinically unnecessary. Existing reviews have focused on one service only, included health professional as well as patient perspectives, or addressed overall demand, including both clinically necessary and unnecessary use . Therefore, there is a need to undertake an in‐depth review that focuses specifically on patients' perspectives of clinically unnecessary service use, to understand more about what drives them to seek care urgently, and attempts to gain a deeper understanding about the reasons for their decisions.…”