Question

Why do young adults prefer to use emergency room services instead of having a primary care physician?

Answer 1

Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.

Methods

Systematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer‐reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework‐based narrative synthesis.

Results

Thirty‐eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty‐nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency‐based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations.

Conclusions

We identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.

The trend of increasing annual demand for emergency and urgent care is consistent across both developed countries and different providers of emergency and urgent care. Studies from the United States, Canada, the United Kingdom, and Australia report that demand for emergency department (ED) care is increasing by as much as 3% to 6% each year.1, 2, 3, 4, 5 In the United States, ED attendance increased from 34.1% to 40.5% per 100 persons between 1996 and 20066 and in England demand has doubled from an estimated 6.8 million ED attenders in 1966 and 19677 to 13.6 million in 2006 and 2007, with a further increase to 14.3 million in 2012 and 2013.7 Demand for urgent care center services in the United Kingdom has also grown, with attendances increasing by 46% between 2006 and 2013.7 In addition, demand for prehospital emergency services has risen dramatically over the past 20 years, rising in England by 125%, from around 4 million calls in 1994 and 1995 to 9 million ambulance calls in 2014 and 20158 and in the U.S. emergency medical services (EMS) transports have risen from 16,000,000 in 2006 to 28,004,624 in 2009.9, 10

The impact of increased demand for emergency and urgent care is well known and includes issues such as ED crowding, increased costs, longer waiting times, and overstretched services. ED crowding has been a recognized problem in the United States since the mid‐1980s,3, 11 occurs in most developed countries,12, 13, 14, 15 and is described as a “worldwide public health problem.”16 Increased demand for services also results in increased service provision costs. For example, in the United Kingdom demand for ambulance services rises annually by 6.5% and increases costs annually by £60 million ($85 million).17

Published literature suggests that some of the increase in demand is attributable to people with primary care problems who use emergency and urgent care services to access care,18 and some studies suggest that large proportions of patients (10%–60%) can be managed using lower‐acuity‐care services.19 However, this is not the only reason and factors contributing to increased demand for emergency and urgent care are often complex and multifactorial. Several studies report that increased demand for emergency and urgent care services is due to a proportionate rise of older people in the population who may have different and more complex care needs.20, 21 Other studies have reported that patients bypass their primary care physician (PCP; also known as a general practitioner [GP]) and instead go directly to urgent or emergency care,22 particularly for out‐of‐hours care and in urban centers.23 Factors such as perceived superior treatment at hospitals,18 lack of access to other care,24 a belief that the problem was serious enough to warrant emergency treatment,24 and lack of awareness of other services19 have all been reported as potential reasons why people choose emergency and urgent care and thus may all impact on why demand for these services is continually increasing. The aim of this study was to systematically review the related literature and, using narrative synthesis, to identify the factors behind patient decisions to access urgent and emergency care, including why patients access emergency and urgent care and how and why they choose which service to access.

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