Table 2 Study and sample characteristics, quality appraisal score, and key themes/identified reasons for emergency department use among qualitative studies

(Bornais, Crawley et al. 2020) [100]

Canada

Qualitative Study, Semi-structured Interview

N = 33 (30 patients, 3 caregivers)

CASP = 10

Mean age: 40.3 ± 17.3 yr (19 to 72 yr); Gender: males = 12, females = 21

Triage: Not specified (included patients determined by an ED nurse as “non-urgent”)

• Practitioner referral

 • Primary care provider was contacted first but referred to ED instead for care (N = 12)

• Efficacy of care (N = 16)

 • Everything “needed” is in one spot

 • Leave with an answer

 • Access to specialists

• Time Saver (N = 26)

• Waiting for primary care provider could take days/weeks

• All testing done same day

(Claver 2011) [86]

United States

Qualitative Study,

Semi-structured interviews

N = 30

CASP = 10

Mean age: 79.3 ± 8.2 yr (56 to 92 yr); Gender: males = 30, females = 0

Triage: Not specified

• Illness Burden—Those with high illness burden felt no choice in decision to do to ER, often told to by someone else, severity of symptoms was a factor

• Knowledge – influenced by knowledge about the course of their chronic illness and acute flare-ups, past experience with ER and potential care ER could provide

• Insufficient self-care – attempts at self-care/treatment at home is not working, most spoke of a wait-and-see method

(Durand, Palazzolo et al. 2012) [93]

France

Qualitative: Semi-structured interviews

N = 87

CASP = 10

Mean age: 38.3 yr ± 16.2 yr [17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78]; Gender: males = 47, females = 40

Triage: Not specified (determined by the nurse whether the presenting complaint could be taken care of by a primary care physician (non-urgent) or not (urgent))

• Fulfil health care needs (35.6%) and anxiety generated by the complaint (29.9%), as well as to relieve pain

• Barriers to primary care providers (e.g., difficulty obtaining appointment, difficulty accommodating their work schedules, understood options and alternatives and made choice)

• Advantages of the ED (e.g., availability of resources, diagnostic tests and treatment, availability of availability of medication, cared for in a single location)

(Long, Knowles et al. 2021)

UK [88]

Qualitative interviews

N = 16 (N = 8 for ED)

CASP = 10

Mean age: 25 yr (18–30 yr); Gender: males = 5, females = 11

Triage: Not specified (in each service, clinicians identified patients they considered had made ‘clinically unnecessary’ use of the service; that is, the patient could have used a lower acuity service or self-care)

Results are pooled for all three settings (i.e., ED results not stratified)

• Concern about the seriousness of symptoms and desire for reassurance – feelings of anxiety and unfamiliarity were large triggers for both psychological and physical symptoms

• Reduced coping capacity due to poor mental health, stress, lack of resources – need for immediate relief (especially for pain), inability to cope due to stressful lives

• Influence of others – influence of others in social networks, perceptions or prior experiences of services (other peoples)

• Concern about the impact of symptoms on daily life – concerned, unable to access GP quickly enough

• Positive and negative views of different services

• Frustration at lack of resolution of an on-going problem, despite previous efforts – waiting long enough for things to improve/resolve

(Gomide MF 2012) [101]

Brazil

Qualitative: interviews

N = 23

CASP = 10

Mean age: 40 yr; Gender: males = 10, females = 13

Triage: Not specified

• Difficulty getting immediate care at other services

• Limited hours of primary care

• Limited time to primary care due to work obligations

• EDs have more diagnostic resources

(Goodridge and Stempien 2019) [98]

Canada

Qualitative Study, Semi-structured interviews

N = 115 (family member accompanied participant in 72 cases)

CASP = 10

Mean age: 79.1 yr (65–98 yr); Gender: males = 47, females = 68

Triage: Canadian Triage and Acuity Scale (CTAS)

• Referred by GP or specialist (N = 36)

• GP was not available (N = 3)

• Accessibility—Ease of access to comprehensive medical, diagnostic and multidisciplinary services in one location. Felt they had exhausted their own repertoire of solutions and needed help to manage issue

• Availability – Only option after business hours

• Quality of Care – thought care quality was superior in ED and offered better continuity of care if they had a complex medical history (e.g., access to tests, treatments, admissions)

• Previous Experience – having tried to access primary care first in the past and being referred to ED influenced decision

(Guttman, Zimmerman et al. 2003) [94]

USA

Structured interview with open-ended questions

N = 77

CASP = 10

Age: 19–25 yr = 11, 26–35 yr = 22, 36–45 yr = 12, 46–55 yr = 8; Gender: males = 41, females = 36

Triage: Not specified (considered “non-urgent” by ED triage staff)

• Conceptions of needs (e.g., relief of pain/discomfort, reassurance, approval/second opinion, treatment, advice, financial)

• Conceptions of appropriateness (e.g., causing concern, after-hours services, unavailability/issues with primary care)

• Preference (e.g., geographical proximity, familiarity, trust, shorter wait, resources/facilities/staff availability, one-stop)

(Henninger, Spencer et al. 2019) [102]

Switzerland

Qualitative, Semi-structured interviews

N = 20 (GP: N = 9; ED: N = 11)

CASP = 10

Mean age: 44.2 ± 34.6 yr (19 to 82 yr); Gender: males = 9, females = 11

Triage: Swiss Emergency Triage Scale (SETS)

Factors influencing decision where to consult (GP or ED):

• Relationship with GP—Those with strong relationships/trust in GP went first to GP, patients liked continuity of care offered by GP

• Perceived nature of the complaint—Chest pain and severe headaches were reason to consult ED

• Anticipated wait time before being seen—Those needing care out of office hours more likely to use ED, rapid answers given by ED appealing to some, booking appointment with GP reduces “wait time” in waiting room

Strong themes in favour of attending ED:

• Technical equipment (e.g., radiology)

• Open hours (24/7)

• Access to specialists

(Howard, Davis et al. 2005) [99]

USA

Qualitative: Structured interview with open-ended questions

N = 31

CASP = 10

Mean age: 34 yr (22–43 yr); Gender: not reported

Triage: Standards set by Kentucky Emergency Nurses Association

• They were unable to obtain an appointment with a PCP (e.g., clinic not open, too late for a reply, unable to get in that day)

• 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

(Keizer Beache and Guell 2016) [87]

St Vincent and the Grenadines, Caribbean

Grounded theory approach: Semi-structured interviews

N = 12

CASP = 10

Age: 19–72 yr; Gender: males = 7, females = 5

Triage: Not specified (“Non-urgent” status determined by triage nurse)

• Habitual use of the ED (i.e., automatic/habitual behaviour; difficulty answering questions (short phrases) regarding roles/functions of AED, unable to differentiate between the roles of AED and district clinics, widely shared practice, socially encouraged)

• Health system (private and public) encouraged or initiated use of AED (i.e., clinic schedule, type of staff/doctor seeking, belief that district clinic staff refers patient to AED, dissatisfaction with the behaviour of clinic staff, free service at AED)

• Deliberate use of AED (i.e., convenience, based on patients’ assessed seriousness of their complaint, past positive AED experiences, confidence in AED, no cost, familiarity with AED)

(Koziol-McLain, Price et al. 2000) [96]

USA

Narrative Descriptive: Unstructured interviews

N = 30

CASP = 10

Mean age: 31 yr (17–60 yr); Gender: males = 8, females = 22

Triage: Not specified (4-level triage system from 1 (life-threatening) to 4; patients included if triage level 2–4)

• Toughing it out (i.e., dealing with the issue before going to ED)

• Symptoms overwhelming self-care measures (i.e., use of over-the-counter medicines not working, medical issue impacts functioning)

• Calling a friend (i.e., social support/advice from friends, relatives, particularly maternal figure)

• Nowhere else to go (i.e., could not access alternative medical services, referred to ED by other healthcare providers)

• Convenience (i.e., work schedules, child care, transportation)

(Kraaijvanger, Rijpsma et al. 2017) [95]

Netherlands

Qualitative Study, Structured interview

N = 30

CASP = 10

Mean age: 46 yr; Gender: males = 19, females = 11

Triage: Manchester Triage System (MTS)

Health Concerns

• Anxiety about presenting symptoms and consequences of being left untreated

• Expecting to need secondary care and wanted access to additional investigations/testing/treatment that are not provided by GP

• Receiving treatment in hospital for the presenting condition already

Practical Issues

• Perceived easier accessibility of the ED (no appointments needed, always accessible, no restrictions, more timely appointments than waiting for GP)

• Distance – not from the area and unfamiliar with where else to access care. Others from the area were closer to ED

(Matifary, Wachira et al. 2021) [97]

Kenya

Qualitative Study, Semi-structured interviews

N = 24

CASP = 10

Mean age: 31.8 ± 8.8 yr (25 to 55 yr); Gender: males = 12, females = 12

Triage: Canadian Triage and Acuity Scale (CTAS)

• Feel unwell, want answers to why they are feeling unwell

• Positive experience in the past (efficient care, satisfied with services provided and quality of care)

• Other services closed

• Influenced by media in the form of advertisements

Some participants just needed a way to access care

(McKenna, Rogers et al. 2020) [104]

UK

Semi-structured interviews, social network mapping

N = 40 (Demographics N = 34)

CASP = 10

Age: 20–40 yr = 14; 40–60 yr = 11, 60–80 yr = 8, > 80 yr = 1; Gender: males = 14, females = 20

Triage: Not specified (included all participants triaged on arrival as “non-emergency”)

System drivers of ED attendance:

• Inner circle of close relational ties did not greatly influence decision

• Health professionals and wider health care system did influence considerably – some perceived them as expert and were influenced, others felt GP were ambiguous in their actions and risk adverse

• Presence of a network member with authority and expertise often helped to reinforce the purpose of ED and push toward primary care

(Palmer, Jones et al. 2005) [91]

UK

Qualitative: Semi-structured telephone interviews

N = 321

CASP = 10

Mean age: 36.6 ± 20.0 yr; Gender: males = 176, females = 145

Triage: Manchester Triage System (MTS)

• AED more appropriate than GP (38.3%)

• GP would send me anyway (17.5%)

• Referred by GP (22.4%)

• Advised by others than GP (13.1%)

• Quicker, wait too long for GP appointment (23.4%)

• More convenient than GP (15.3%)

• GP surgery closed/not available (30.5%)

• No GP/GP more than 25 miles away (14.6%)

• Already tried GP without good outcome (4.7%)

• Other (1.6%)

(Pförringer, Pflüger et al. 2021) [103]

Germany

Qualitative, interview for open-ended questionnaire

N = 235

CASP = 10

Age: < 30 yr = 88, 30–49 yr = 69, 50–67 yr = 49, > 67 yr = 29; Gender: males = 125, females = 110

Triage: Guidelines of the German Society of Traumatology

Descriptive statistics were used to gain quantitative statements:

• Immediate help (45.9%)

• Fast treatment by a specialist (35.4%)

• Broad diagnostic tools (22.8%)

• High quality treatment (17.9%)

• Family doctor closed (12.6%)

• Other (17.9%)

• Fast admission to hospital (9.3%)

• Attestation (5.7%)

• Family doctor on holiday (4.4%)

• Blood analysis (4.4%)

• Free medication (3.3%)

• Thorough consultation (2.8%)

• Shorter waiting time (2.4%)

Replacement of family doctor unknown (1.2%)

(Shaw, Howard et al. 2013) [89]

USA

Qualitative: Semi-structured Interviews

N = 30

CASP = 10

Mean age: 40 yr (21–63 yr); Gender: males = 18, females = 12

Triage: Emergency Severity Index (ESI)

• No knowledge of other primary care options

• Being instructed by a medical professional

• Facing access barriers to their regular source of care

• Perceiving racial issues with a primary care option

• Defining their health care need as an emergency that required ED services

• Facing transportation barriers to other primary care options

(van der Linden, Lindeboom et al. 2014) [90]

Netherlands

Observational: Structured interview by nurse

N = 3028

CASP = 10

Self-Referred: Mean age: 32.3 ± 18.6 yr; Gender: males = 1636, females = 1392

Triage: Not specified (5-level triage system; included patients with levels 1–3 “life-threatening, very urgent, or urgent” and levels 4–5 “standard or non-urgent”)

Among the self-referred patients, 1751 answered the question (58%):

• Accessibility and convenience

• Perceived medical necessity

• Not thought about going to the GP

• Not having a regular GP

• Familiarity

• Dissatisfaction with GP

• Referral by non-professionals

• Language barriers

(Agarwal, Banerjee et al. 2012) [92]

UK

Qualitative: Semi-structured Interviews

N = 23

CASP = 9

Age < 50 yr: Gender: males = 4, females = 6;

Age 50–69 yr: Gender: males = 4, females = 2; Age 70 + : Gender: males = 4, females = 3

Triage: Not specified (initial assessment

by an experienced consultant in the ED identified patients suitable to be cared for in an alternative service including primary care)

• Anxiety about their health and the reassurance arising from familiarity with knowledge of the emergency service

• Issues surrounding access to general practice (e.g., no appointments, too long to wait)

• Perceptions of the efficacy of the service (e.g., more thorough investigation)

• Lack of alternative approaches to care

(Benger and Jones 2008) [85]

UK

Qualitative, semi structured questionnaire

N = 200

CASP = 9

Mean age: 58 yr (16–91 yr); Gender: males = 96, females = 104

104 patients (52%)

Triage: Not specified (authors excluded “triage category 1)”

Top five reasons why patients choose to attend ED (N = 57):

• Perceived severity or urgency of their condition (51%)

• Previous experience (12%)

• Ease and convenience (7%)

• Housebound (7%)

• Primary care services are not available out of hours (7%)

(Read, Varughese et al. 2014) [105]

Quatar

Qualitative: Semi-structured interviews

N = 100

CASP = 7

Mean age: 33 yr; Gender: females = 100

Triage: Not specified (non-urgent ED females classified with low-acuity conditions, excluding minor trauma and lacerations)

• Directed by employer to attend ED (40%)

• Advised to come by family (35%)

• Faster care and accessibility (98%)