Table 3 Study and sample characteristics, NIH quality appraisal score, and key themes/identified reasons for emergency department use among quantitative studies

(Afilalo, Marinovich et al. 2004) [63]

Canada

Observational: Secondary analysis of a prospective cross-sectional study

N = 454

NIH = 7

Mean age: 43.3 ± 18.1 yr; Gender: males = 224, females = 230

Triage: Canadian Triage and Acuity Scale (CTAS)

• Accessibility (30.1%)

• Perception of ED-specific need (22.1%)

• Referral/follow up to the ED (20.2%)

• Familiarity with the ED (11.1%)

• Trust of the ED (7.4%)

• No specific reason (7.1%)

(Amiel, Williams et al. 2014) [64]

UK

Survey Questionnaire

N = 649

NIH = 7

Mean age: 35 yr (18–84 yr); Gender: males = 266, females = 383

Triage: Not specified (nurse streams patients into one of four categories: “minor illness,” “minor injury,” “emergency for transfer,” or “see and treat”)

• Quicker than a GP appointment (28%)

• Nearest place to home or work (23%)

• Best place for my particular problem (10%)

• Recommended by friends, family or colleague (10%)

• Thought there would be a shorter wait (8%)

• More confidence in advice than given by own GP (7%)

• Did not think about going anywhere else (6%)

• Did not have a GP to go elsewhere (3%)

• Wanted a second opinion (2%)

• Other (3%)

(Cheek, Allen et al. 2016) [56]

Australia

Cross-sectional Survey

N = 138

NIH = 7

Mean age: 47 ± 21.1 yr (18–87 yr); Gender: males = 63, females = 75

Triage: Australian Institute of Health and Welfare (AIHW)

Questions listed on the survey verbatim:

• I am able to see the doctor and have any tests or x-rays all in the same place at the ED (71.7%)

• My GP surgery was closed (57.2%)

• I am not happy with the time I have to wait to acquire an appointment with a GP (34.8%)

• The ED is closer to home or work than the GP surgery (34.8%)

• I feel the medical treatment is better at the ED (32.6%)

• I thought the GP would send me to the ED anyway (31.2%)

• I have to wait too long to see the GP (29.7%)

• I do not see the same GP when I attend my GP practice (29.0%)

• My GP referred me to the Ed (16.7%)

• I find it difficult to understand my GP (15.9%)

• My family has traditionally used the Ed for our health care (15.9%)

• I did not think my GP had the required equipment (15.2%)

• I prefer the hospital environment to the GP surgery (14.5%)

• I do not like making appointments and prefer the ED as I can attend when I want (13.0%)

• I wanted to see a doctor I do not know (13.0%)

• I wanted a second opinion (10.9%)

• I am on holiday away from usual GP (2.9%)

• I did not want GP to know about this particular problem (1.4%)

• I preferred to see a female doctor and thought I could at the ED (0%)

(Coelho Rodrigues Dixe, Passadouro et al. 2018) [66]

Portugal

Cross-sectional survey administered via structured interview

N = 357

NIH = 7

Mean age: 54.51 ± 20.9 yr (18 to 92 yr); Gender: males = 144, females = 213

Triage: Manchester Triage System (MTS)

• Disease justified ED use (91.7%)

• Can undergo all medical examinations on same day (65.6%)

• Wanted to be examined by specialist (53.9%)

• Difficult to schedule an appointment at healthcare center (44.3%)

• Quicker to be examined at hospital (38.1%)

• Matter of habit (26.75%)

• Unsatisfied with healthcare center in similar situations (26.6%)

• Worsening of chronic disease during follow-up in outpatient visit (21.0%)

• Healthcare center closed, did not know where to go (20.7%)

• Doctor was not at the healthcare center, no alternative (16.4%)

• No vacancy at healthcare center, I had no alternative (15.7%)

• Visit hours at healthcare center weren’t compatible with work/school (15.4%)

• Closer to the hospital (15.4%)

• Don’t have family doctor (14.7%)

• Hoping to be hospitalized (5.4%)

• Have a private doctor, don’t usually use healthcare center (9.6%)

(Coleman, Irons et al. 2001) [26]

UK

Cross-Sectional Survey

N = 255

NIH = 7

Age: < 35 yr = 145, > 35 yr = 110; Gender: males = 136, females = 119

Triage: Not specified (five-colour system (black, red, blue, green, yellow) with green meaning a new illness or injury that is non-urgent, yellow meaning a long-standing issue)

• Perceptions of seriousness (76%)

• Positive experiences at ED (70%)

• Seeking a specific service (68%)

• Awareness of other services (62%)

• Processes and patient’s time (56%)

• Advised to come by others (43%)

• Availability of other services (38%)

• Seeking assurance (38%)

• Convenience of access (24%)

• Patient preference (11%)

(Ghazali, Richard et al. 2019) [72]

France

Cross-sectional survey

N = 598

NIH = 7

Median age: 38 yr (IQR 27–50); Gender: males = 475, females = 123

Triage: French Emergency Nurses Classification in Hospital Scale, Classification Infirmière des Malades aux Urgences (CIMU)

• Expectation of getting hospital-based care, including access to further testing or hospitalization (N = 171)

• Personal convenience (geographical proximity, opening hours) (N = 147)

• Not having to pay for service (N = 20)

Motivations:

• Workplace accident (2.8%)

• Suggested by peers (0.5%)/professional (9.7%)

• Second opinion (3.6%)

• Intense pain (4.5%)

• Additional testing (26.3%)

• Appointment hours (1.3%)/After business hours (5.2%)

• Hospitalization (2.3%)

• Unavailable primary care provider (19.2%)

• Lack of upfront payment (3.7%)

• Geographic proximity (17.7%)

• Already taken care of in this hospital (3.2%)

(Han, Ospina et al. 2007) [31]

Canada

Questionnaire by either interview or self-administered, open-ended questions

N = 894

(N = 421, 47% of CTAS 4–5)

NIH = 7

Mean age: 44.1 ± 19.7; Gender: males = 438, females = 456

Triage: Canadian Triage and Acuity Scale (CTAS)

• Perceived severity of their health problems (N = 230)

• Quality of care in the ED (N = 185)

• Physician availability (N = 137)

• Professional referral (N = 100)

• Perceived rapidity of care in the ED (N = 80)

• Felt it was only option (N = 76)/No physician available (N = 58)

• ED was convenient (N = 71)

(Hodgins and Wuest 2007) [70]

Canada

Structured interviews

N = 1612

NIH = 7

Mean age: 43.0 yr (16–93 yr); Gender: males = 629, females = 983

Triage: Not specified (“non-urgent” determined by a health professional)

16 total items; only 7 reported on by authors (no % provided)

• Severity of symptoms (e.g., not willing to wait to see GP for pain)

• Concern it will get worse

• No other option

• No availability of GP

• Convenience of service

• Needed service only available at ED

• Tests only available at ED

• Advised to come from family/friends

(Jalili, Shirani et al. 2013) [32]

Iran

Cross-sectional survey administered via structured interview

N = 1923 (non-urgent = 400)

NIH = 7

Age: 15–49 yr = 1571, > 50 yr = 727 (non-urgent: 15–49 yr = 334, > 50 yr = 66); Gender: males = 1196, females = 727 (non-urgent: males = 242, females = 158)

Triage: Canadian Triage and Acuity Scale (CTAS)

• Obtaining rapid care (77%)

• Proximity (52.8%)

• Low cost (20.8%)

• Unavailability of clinic area (19.8%)

• Better care (11.3%)

• Perception of urgent problems/urgency of the problem (10.8%)

• Having medical records in this hospital (10.3%)

• Being referred by a clinic or office (7.3%)

• Being an employee of this hospital (7.3%)

• Dissatisfaction with clinic or office (4.5%)

• Being brought by EMS ambulance (0.5%)

• No reasons mentioned (0.5%)

• Miscellaneous (0.5%)

(Lee, Lau et al. 2000) [75]

Hong Kong

Telephone interviews,

using questionnaires

N = 1374

NIH = 7

Age: 0–19 yr = 561, 20–64 yr = 728, 65 +  = 85; Gender: males = 735, females = 639

Triage: Not specified (blind retrospective review of patient charts conducted by an independent panel of emergency physicians; patients were divided into two categories (i.e., accident and emergency cases or GP-type cases)

• Could not afford GP (61.2%)

• Proximity (21.2%)

• Better quality service at ED (13.4%)

• Efficient diagnosis (2.9%)

• Symptoms getting worse (0.1%)

(Lobachova, Brown et al. 2014) [35]

USA

Cross-Sectional Survey

N = 1062

NIH = 7

Mean age: 43.0 ± 22.0 yr; Gender: males = 552, females = 510

Triage: Not specified

• I believed that my problem was serious (61%)

• My care provider told me to come (35%)

• I thought it was an emergency (26%)

• My illness occurred after hours (21%)

• It was suggested by family/friend (13%)

• I have no primary care provider (8%)

• I thought it was unnecessary to contact my regular provider (8%)

• The ED is convenient (8%)

• My primary care provider is not from here (7%)

• I could not get an appointment with MD (6%)

• I spoke to a specialist (5%)

• I did not know where else to go (3%)

• I don’t know (0.5%)

• I have no insurance (1%)

• Other (16%)

• Unspecified (16%)

(Marco, Weiner et al. 2012) [36]

USA

Cross-Sectional Structured Survey via Interview

N = 292

NIH = 7

Age: 18–39 yr = 140, 40–64 yr = 100, 65 +  = 49; Gender: males = 136, females = 156

Triage: Not specified

• Convenience/location (41%)

• No GP (37%)

• Institutional preference (23%)

• Emergency medical condition (19%)

• Issues with primary care (e.g., lack of available appointments, couldn’t get through, long wait, no on-call) (17%)

• Physician referral (14%)

• Primary care institutional affiliation (12%)

• Don’t know, didn’t think about it, no reason (6%)

• Other (7%)

(Masso, Bezzina et al. 2007) [37]

Australia

Cross-Sectional Survey

N = 397

NIH = 7

Mean age: 38 yr (0–96 yr); Gender: males = 222, females = 175

Triage: Australasian Triage Scale (ATS)

• My health problem required immediate attention (67.3%)

• I am able to see the doctor and have any tests or X-rays all done at the same place (51.3%)

• My health problem was too serious or complex to see a GP (38.2%)

• I feel the medical treatment is better at the ED (15.4%)

• I am not happy with the time I have to wait to get to an appointment with a GP (12.6%)

• It is easier for me to go to the ED” (8.4%)

• I am not able to get in as a patient at GP surgery as the books are closed (7.6%)

• I wanted a second opinion (5.7%)

• I do not like making appointments (4.2%)

• I usually prefer to talk a doctor a don’t know about my health problems (3.4%)

• I did not want my GP to know about this health problem (1.6%)

(Miyazawa, Maeno et al. 2019) [73]

Japan

Cross-sectional survey

N = 231

(Reported on Non-urgent ED subset = 84)

NIH = 7

Mean age: 43.5 ± 18.5 yr; Gender: males = 51, females = 33

Triage: Japan Triage and Acuity Scale (JTAS)

Inappropriate use group (N = 84)

• Desired to be cured quickly (92.5%)

• Wanted a doctor’s opinion (90.6%)

• Wanted to know whether the condition was serious (83.9%)

• Condition was not improving (80.6%)

• Wanted a prescription (76.7%)

• Wanted a laboratory test done (65.1%)

• Desire for treatment by a specialist (59.3%)

• Recommended by others (45.8%)

• Over-the-counter medicine was not working (35.6%)

• Wanted to know if they could attend work, school, events (24.1%)

• Wanted an intravenous drip (20.7%)

• Inability to take time off from school or work during the day (38.7% of inappropriate group)

(Penson, Coleman et al. 2012) [43]

UK

Observational: Survey

N = 261

NIH = 7

Age: 14–34 yr = 108, 35–55 yr = 77, 55 + yr = 77; Gender: males = 140, females = 121

Triage: Not specified (“minor” injury were fined by a list of explicit criteria

Ranges reflect the sub-themes of reasons within each overall category endorsed by patients:

• Availability of other services (i.e., no GP or no availability) (6–69%)

• Awareness of other services (i.e., not sure where to go, unsure of other services, when open) (16–46%)

• Patient preferences (i.e., not wanting to see their GP, can’t always see the same one, not wanting to bother them) (6–15%)

• Positive experiences of ED (i.e., confident, happy) (60–74%)

• Processes and patient’s time (i.e., GP would refer to ED anyway, seen quicker, do not have to wait for appointment) (17–48%)

• Convenience of access (i.e., location, ease) (18–29%)

• Perceptions of seriousness (21–98%)

• Reassurance (91%)

• Second opinion (25%)

• Directed by others (36–78%)

• Seeking particular services (4–84%)

(Schumacher, Hall et al. 2013) [45]

USA

Structured interviews based on a survey

N = 492

NIH = 7

Mean age: 41 ± 17 yr; Gender: males = 221, females = 271

Triage: Emergency Severity Index (ESI)

• Right place to go (92%)

• Emergency (89%)

• Worried (93%)

• Too much pain (73%)

• Too sick or injured (52%)

• Do not like usual (13%)

• Medical records are at ED (41%)

• Better care at the ED (61%)

• Always get care in ED (47%)

• Like environment of the ED (25%)

• No insurance (21%)

• Financial (22%)

• MD-refused insurance (3%)

• One stop (63%)

• No appointment necessary (45%)

• Closest or easiest place (54%)

• No place to go (55%)

• Only place open (26%)

• Language (33%)

• Family or friends (32%)

(Ward, Huddy et al. 1996) [69]

UK

Cross-sectional survey (single question)

N = 970

NIH = 7

Age range: 21–30 yr (344/965 patients with complete data); Gender: not reported

Triage: Not specified

Question answered by 339 patients:

• Problem not appropriate for GP (27.1%)

• Not convenient to see GP (22.4%)

• Advised by health professional 39 (11.5%)

• Second opinion (9.7%)

• Did not try to see GP (9.7%)

• Appointment not available with GP (7.4%)

• Unable to contact GP (6.2%)

• Dissatisfied with GP (4.4%)

• Other (1.5%)

(Watson, Ferguson et al. 2015) [53]

UK

Cross-sectional survey

N = 81

NIH = 7

Mean age: 42.2 ± 17.9 yr; Gender: males = 36, females = 43; missing = 2

Triage: Not specified (non-urgent patients determined to have a “common or self-limiting or uncomplicated conditions which may be diagnosed and managed without medical intervention”)

Major categories (range reported by subcategories of reasons)

• Convenient location (1.2%-51.9%)

• Knowing, feeling comfortable, or trusting the staff (1.2%-34.6%)

• Condition too serious to go to GP or chemist (27.2%-30.9%)

• Previously attended GP or chemist but condition not improved (3.7%-16.0%)

• Have to wait longer for a GP appointment (37.0%)

• Prefer not to go to GP or chemist (3.7%-4.9%)

• Cost of treatment (1.2%)

(Afilalo, Guttman et al. 1995) [16]

Canada

Cross-sectional survey administered via structured interview

N = 849

(N = 186 for Category II and III interviews)

NIH = 6

Total sample: Age: < 65 = 72.7%; Gender: males = 418, females = 431

Triage: Not specified (three-level list of explicit criteria)

• Other clinic is closed (25.0%)

• Perception of serious illness (20.7%)

• Familiarity or trust in the ED (12.1%)

• Proximity (10.7%)

• Unaware of services available elsewhere (8.6%)

• Dissatisfied with other out-patient facilities (8.6%)

(Al-Otmy, Abduljabbar et al. 2020) [17]

Saudi Arabia

Cross-sectional survey administered via structured interview

N = 400 (N = 314 non-urgent)

NIH = 6

Total Sample: Mean age: 50.3 ± 19.7 yr (14–98 yr); Gender: males = 181, females = 219

Triage: Canadian Triage and Acuity Scale (CTAS)

For those triaged as non-urgent (N = 314)

• Participant felt their condition was urgent (41.1%)

• Easier accessibility (26.1%)

• Limited resources and services in the primary healthcare centre (19.4%)

• Difficulty getting an appointment (11.8%)

• Referred from primary healthcare centre to ED (3.5%)

(Alyasin and Douglas 2014) [18]

Australia

Cross sectional survey

N = 350

NIH = 6

Mean age: 32.1 ± 12.2 yr (18 to 80 yr); Gender: males = 202, females = 148

Triage: Canadian Triage and Acuity Scale (CTAS)

• Do not have a regular healthcare provider (63.4%)

• Can receive care on the same day without an appointment (62.6%)

• Convenience and access to medical care 24/7 (62.6%)

• ED gives better care than other health services in the area (44.6%)

• Can access investigation such as blood tests/x-rays (37.4%)

Urgency of problem (22.3%)

(Atenstaedt, Gregory et al. 2015) [55]

UK

Cross-Sectional Survey

N = 806

NIH = 6

Age: 0–15 yr = 12%, 16–29 yr = 27%, 30–69 yr = 57%, 75 + yr = 4%; Gender: males = 459, females = 347

Triage: Manchester Triage System (MTS)

• Thought might need radiograph (46%)

• Did not think GP could help (29%)

• GP was not available (19%)

• Could be seen quicker at ED (11%)

• Thought might need to go to hospital (10%)

• Wanted to see specialist (9%)

• Thought might need stitches (6%)

• ED nearer than other service (6%)

• Was not aware of other services (3%)

• Does not have GP (3%)

• Did not want to bother GP (3%)

• Wanted a second opinion (3%)

• Thought might need tetanus shot (3%)

• ED is easier to get to than other service (2%)

• Dentist was not available (1%)

• Thought might need blood test (1%)

(Baker, Stevens et al. 1995) [20]

USA

Cross-sectional survey

N = 1190

NIH = 6

Mean age: 37 yr ± 14.0 yr; Gender: males = 524, females = 666

Triage: Not specified (four-level triage system based on a list of explicit criteria)

• Among 58% sample who attempted to see their GP, they failed due to cost (43%), lack of insurance (36%), and inability to obtain an appointment rapidly (19%)

• Among 38% who did see their GP in the preceding week, 68% were referred to ED

• Among all patients, 89% said that they needed to be seen immediately

(Burchard, Oikonomoulas et al. 2019) [25]

Germany

Cross-sectional survey

N = 499

NIH = 6

Median Age: 32 yr (IQR 50–22); Gender: males = 300, females = 199

Triage: Manchester Triage System (MTS)

• Deemed their medical condition something that needed urgent or emergency diagnosis and treatment (63.1%)

• A GP would be unable to treat their medical problem (74%)

• Expected a hospital admission or in-patient treatment was necessary (2.4%)

• Factors guiding decision (ED over GP):

• Technical equipment (3.5%)

• No GP (1.4%)

• 24/7 Access (4.3%)

• Negative experience (0.4%)

• Waiting experience (10.3%)

• I do not like to answer this question (80.1%)

(Barbadoro, Di Tondo et al. 2015) [21]

Italy

Cross sectional survey

N = 61

NIH = 6

Age: 18–65 yr = 52, ≥ 65 = 9; Gender: males = 33, females = 28

Triage: Not specified (“non-urgent” patients defined as having no active symptoms or were recent and minor, without any feeling of emergency and he/she desires a check-up, a prescription refill or a return-to work release)

Of the non-urgent participants (N = 61), the following were present motivations for accessing ED:

• Urgency perceived by patient (N = 23)

• Recent traumatic injury (N = 14)

• Difficulty contacting GP (N = 9)

• Greater confidence in the hospital (N = 14)

• Previous medical therapy without benefit (N = 10)

• Too long to book exams (N = 20)

• ED has more tools to solve clinical problems (N = 21)

• Easy accessibility of ED (N = 5)

(Dawoud, Ahmad et al. 2015) [57]

Saudi Arabia

Cross sectional study,

Interviewed with structured questionnaire

N = 300

NIH = 6

Age: ≤ 15 yr = 80, 16–31 yr = 105, 32–60 yr = 93, > 60 yr = 22; Gender: males = 152, females = 148

Triage: Canadian Triage and Acuity Scale (CTAS)

Reasons why patients went to ER instead of primary healthcare center:

• Limited working hours (60.8%)

• Limited services and resources (60.4%)

• Mistrust of health centers (24.6%)

• Lack of experience among the medical staff (10.1%)

• Lack of knowledge of the health centers (7.1%)

• Dissatisfaction with the treatment provided (7.1%)

• Lack of effective diagnosis (6.3%)

Reason why patients went to ER despite having health insurance:

• Closest governmental hospital (69.8%)

• Other hospital does not receive some cases (44.4%)

• Congestion in other hospitals (14.3%)

• Insurance requirements have not yet been completed (12.7%)

• Trust the governments treatment more (4.8%)

(de Valk, Taal et al. 2014) [27]

Netherlands

Cross-Sectional Survey

N = 436

NIH = 6

Age: 18–35 yr = 54, 35–65 yr, 65 +  = 7; Gender: males = 251, females = 185

Triage: Not specified

• Belief that ED could provide care that the GP could not (28%)

• Specialist that patient sees already at that hospital (17%)

• There was not a GP nearby (16%)

• Could get help earlier at ED (15%)

• ED was located nearby (11%)

• Did not have a GP (11%)

• Could not contact the GP (7%)

• Unsure where to locate a GP (5%)

• Previous negative experience with GP (4%)

• No trust in GP (3%)

• Advised by others to go (3%)

• Belief the complaint was urgent (2%)

(Diserens, Egli et al. 2015) [76]

Switzerland

Observational: Survey

N = 516 (2000)

N = 581 (2013)

NIH = 6

Sample from 2000: Mean age: 46.4 ± 22.0 yr; Gender: males = 294, females = 222

Sample from 2013

Mean age: 44.5 ± 20.0 yr; Gender: males = 314, females = 267

Triage: Swiss Emergency Triage Scale (SETS)

Reasons for Self-Referral to ED (2000 vs. 2013)

• Unawareness of alternatives for emergencies (12.5% vs. 5.4%)

• Excellence of the institution and access to specialists (9.8% vs. 3.8%)

• Usual place of consultation (6.7% vs. 4.1%)

• Easy access (3.4% vs. 5.2%)

• Dissatisfaction with treatment or appointment with GP (0.7% vs. 1.7%)

• Convenience of unscheduled appointment (0.5% vs. 1.7%)

• Paramedics choice (0.5% vs. 1.7%)

• Other (0.7% vs. 1.3%)

(Field and Lantz 2006) [29]

Canada

Cross-section survey

N = 235

NIH = 6

Age: not reported; Gender: not reported

Triage: Canadian Triage and Acuity Scale (CTAS)

• Access to a specific service (49%)

• Obtain rapid treatment for a perceived urgent problem (43%)

• Limited access to family physician (23%)

• Referred to the ED (20%)

• Did not have a family physician (3%)

(Gentile, Vignally et al. 2010) [71]

France

Cross-sectional survey

N = 85

NIH = 6

Mean age: 36.3 ± 11.7 yr (18–70 yr); Gender: males = 50, females = 35

Triage: Not specified (patients deemed “non-urgent” by triage nurse)

• Were unable to contact GP (33%) or trouble accessing their usual source of care (22.3%)

• Referrals: self (76%), GP (17.6%), for medico-legal reasons by employer/police (5.9%)

• Attending due to the pain (65.8%)

• Need for diagnostic investigations (37.6%)

• Needing consultation for traumatological problems

(Gill and Riley 1996) [30]

USA

Cross-Sectional: Structured interview

N = 268

NIH = 6

Age: 18–39 yr = 138, 40–64 yr = 54, 65 + yr = 5; Gender: males = 132, females = 135, unknown = 1

Triage: Not specified (non-urgent patients defined as those who “may safely wait several hours or more for evaluation”)

Reasons for attending ED (perceived urgency: urgent vs. non-urgent):

• Emergency department closer (33 vs. 39%)

• Emergency department faster (19 vs. 25%)

• No regular source of care (19% vs. 16%)

• Likes emergency department service (16% vs. 18%)

• Regular source of care not accessible (20% vs. 8%)

• Urgent problem (16% vs. 14%)

• Referred (11% vs. 16%)

• More convenient (11% vs. 12%)

• Financial (7% vs. 8%)

• Better medical care (6% vs. 6%)

(Idil, Kilic et al. 2018) [81]

Turkey

Cross-sectional survey

N = 624

NIH = 6

Mean age: 38.4 ± 14.4 yr; Gender: males = 326, females = 298

Triage: Not specified (three-level colour system with green indicating lowest urgency; patients do not require urgent interventions and could be treated outside the ED in polyclinics or by their family physicians)

• Able to get examined more quickly (36.4%)

• Not being able to book early appointments with alternative health units (30.9%)

• No given reason for preference to the ED (20.2%)

• ED is physically closer than the family physician (12.8%)

• Visited ED for complaints when they were at hospital for a different reason (12.3%)

• Other reasons (get medications prescribed, get incapacity report, or seek medical counselling services, etc.) (8.0%)

(Jiang, Ye et al. 2020) [33]

China

Cross-sectional survey

N = 545

NIH = 6

Age: > 18 = 152, 19–44 = 217, 45–64 = 123, > 65 = 53; Gender: males = 271, females = 274

Triage: Modified Emergency Severity Index (ESI)

• Perceived severity of illness and urgent treatment needed (68.6%) – illness is severe, advised by family/friends, need reassurance for their condition

• Poor access of alternative services (26.4%) – can’t get appointments, can’t get specific services elsewhere, alternatives not opened at this hour

• Referral by medical staff (24.6%)

• Convenience and advantages of ED services (21.5%) – easier to get appointment, evaluated/treated quickly, quality of care is superior, staff qualifications

• Unsure where else to go (4.6%)

• Regard ED as a regular medical resource (4.4%)

• Other reasons (0.4%)

(McGuigan and Watson 2010) [38]

UK

Cross-Sectional: Semi-structured telephone interviews

N = 196

NIH = 6

Age: Not reported; Gender: Not reported

Triage: Not specified

• Perceived appropriateness of condition (48%)

• After taking advice from others (mostly family) (35%)

• Anticipation of referral by GP (3%)

• Accessibility of ED (6%)

• Unavailability of GP (5%)

• Other (1%)

(Moll van Charante, ter Riet et al. 2008) [79]

Netherlands

Postal questionnaires

N = 224

NIH = 6

Median age: 33 yr (IQR 30); Gender: males = 175, females = 49

Triage: Not specified

• Additional investigations were necessary (36%)

• ED physician is best qualified for the problem (30%)

• ED is more accessible than the GP (16%)

• Related to a recent hospital contact or procedure (5%)

• Did not want to disturb the GP or no GP available (4%)

• Other (5%)

• No response (4%)

(Nelson 2011) [80]

Scotland UK

Telephone interviews using structured questionnaire

N = 27

NIH = 6

Age: 16–40 yr = 20, 40 +  = 7;

Gender: males = 13, females = 14

Triage: Not specified

• Need for x-rays (37%)

• Referred by their GP (15%)

• Advised by the health centre receptionist to attend the ED (7%)

• Unable to obtain a GP appointment (4%)

(Norredam, Mygind et al. 2007) [67]

Denmark

Cross-sectional survey

N = 3426

NIH = 6

Mean age: 0–14 yr = 617, 15–24 yr = 624, 25–44 yr = 1343, 45 +  = 781; Gender: males = 1925, females = 1501

Triage: Not specified

• The ED is most relevant to my need (63%)

• I was referred by a primary caregiver (24%)

• I could not get in contact with a GP (13%)

(Northington, Brice et al. 2005) [39]

USA

Cross-sectional survey

N = 279

V6

Mean age: 37.4 ± 14.9 yr; Gender: males = 154, females = 125

Triage: Emergency Severity Index (ESI)

• Better care (76.1%)

• Urgency (73.6%)

• Immediacy (68.6%)

• Payment flexibility (41.9%)

• Expediency (39.7%)

(Oetjen, Oetjen et al. 2010) [41]

USA

Cross-Sectional: Survey questionnaire

N = 438

NIH = 6

Age: 2–18 yr = 127, 19–50 yr = 197, 50–80 yr = 114; Gender: males = 29%, females = 70%

Triage: Not specified (non-urgent defined as “those cases in which the patient does not require immediate care or attention within a few hours”)

• Patient believed condition was serious (72%)

• Primary care physician referred them (57%)

• After-hours (9%)

• Insurance (8%)

• ED was more convenient: quality (10%)

• ED was more convenient: location (14%)

• ED was more convenient: staff (51%)

• Friends recommended coming (9%)

(Oktay, Cete et al. 2003) [42]

Turkey

Cross-sectional survey

N = 1155

NIH = 6

Mean age: 44.9 ± 18.1 yr; Gender: males = 503, females = 652

Triage: Canadian Triage and Acuity Scale (CTAS)

• Proximity to ED (19.8%)

• Satisfaction with care (12.5%)

• Pain and worsening of symptoms (11.5%)

• Clinic care unavailable (11.3%)

• Quick care and laboratory results (8.5%)

• Always get care in this hospital (7.6%)

• Perception of serious illness (6.4%)

• Told to go to ED by relatives or others (4.7%)

• Trust out ED care (2.8%)

• Thought symptoms would become intensified (2.6%)

• Told to come to our ED for follow up (2.4%)

• Relatives work in our ED (2.1%)

• Miscellaneous (7.8%)

(O’Loughlin M 2019) [40]

Australia

Cross-sectional survey

N = 1000

NIH = 6

Mean age: 48.6 ± 19.0 yr; Gender: males = 493, females = 507

Triage: Not specified (non-urgent patients were those with “potentially avoidable general practitioner (PAGP)-type presentations”)

• No choice/urgent problem (35.5%)

• Best place for problem (25.0%)

• Services in one location (11.6%)

• Open 24 h (4.6%)

• Quicker than a general practice (3.2%)

• Need admission (2.6%)

(Ragin, Hwang et al. 2005) [68]

USA

Questionnaires and interviews

N = 1536

NIH = 6

Mean age: 45.9 ± 19.3 yr; Gender: males = 685, females = 851

Triage: Not specified

• Medical necessity – perceived ED was the place to be (95.0%)

• Convenience (86.5%)

• Preference of ED over alternate services (88.7%)

• Affordability (25.2%)

• Limitations of insurance (14.9%)

(Redstone, Vancura et al. 2008) [59]

USA

Cross-sectional survey

N = 240

NIH = 6

Mean age: 45 yr; Gender: males = 76, females = 164

Triage: Emergency Severity Index (ESI)

• Could not wait 1–2 days (93%)

• ED more convenient (62%)

• Need a test not available at GP (51%)

• Problem too complex for GP (45%)

• Advised to go to ED (49%)

• Perceived need of hospital admittance (24%)

(Selasawati, Naing et al. 2007) [46]

Maylasia

Cross-sectional survey

N = 170 (case)

N = 170 (control)

NIH = 6

Case (ED Patients; N = 170): Mean age: 36.7 ± 13.6 yr; Gender: males = 97, females = 73

Control (Outpatients; N = 170): Mean age: 40.2 ± 14.6 yr; Gender: males = 46, females = 124

Triage: Triage guideline of Hospital Kuala Lumpur (HKL) and Hospital University Kebangsaan Malaysia (HUKM), American College of Emergency Physician (ACEP) and ED criteria of Davis Medical Centre

• Due to severity of illness (85%)

• Can’t go to OPD during office hours (42%)

• ED near house (27%)

• Better treatment in ED (26%)

• Staff or family member (17%)

• No other place to go (15%)

• Financial problem (8.8%)

(Shah, Shah et al. 1996) [47]

Kuwait

Cross-Sectional Survey

N = 1986

(N = 1212 non-urgent, self-referred only)

NIH = 6

(Non-urgent, self-referred only; N = 1212): Age: < 25 yr = 266, 25–34 yr = 392, 35–49 yr = 349, 50 +  = 205;

Gender: males = 691, females = 521

Triage: Not specified (4-level triage system from emergency level 1 to non-urgent level 4)

Preference

• ED better or clinic worse/medicine not available (27.8%)

Accessibility/availability

• Accessibility/availability of ED (59.8%)

• Hospital staff (14.0%)

• Clinic closed/not available/do not know clinic schedule (7.5%)

• ED close by or convenient (13.2%)

• Regular patient (12.1%)

• Refused by primary care physician (2.0%)

Perceived Urgency

• Perceived condition to be urgent (10.7%)

Other (1.6%)

(Siminski, Cragg et al. 2005) [48]

Australia

Cross-sectional Survey

N = 400

NIH = 6

Mean age: not reported; Gender: not reported

Triage: Australian Triage Scale (ATS)

• Problem too urgent (80%)

• See doctor and testing done in same place (74%)

• Problem too serious/complex (53%)

• Medical treatment better at ED (34%)

• Not happy with GP waiting time (24%)

• Easier to get to the ED (21%)

• Not able to see GP as books are closed (16%)

• Second opinion (14%)

• Do not like making appointments (12%)

• No charge for X-rays or medicine (10%)

• No charge to see a doctor (9%)

• Traditional use by family (9%)

• Prefer doctor I don’t know (6%)

• Prefer ED environment (5%)

• Did not want the GP to know (2%)

• Female doctor (2%)

• Doctor/interpreter with native language (2%)

• Aboriginal health staff (2%)

(Steele, Anstett et al. 2008) [49]

Canada

Cross-sectional survey

N = 137

NIH = 6

Mean age: not specified; Gender: not specified

Triage: Canadian Triage and Acuity Scale (CTAS)

• Needed treatment as soon as possible (38.7%)

• Needed a specific service offered in the ED (32.8%)

• Walk-in clinic was closed (24.8%)

• Family physician’s office was closed (21.9%)

• Could not wait for appointment with family physician (16.8%)

• Did not have a family physician (4.4%)

(Thornton, Fogarty et al. 2014) [50]

New Zealand

Cross-sectional survey

N = 421

NIH = 6

Mean age: 37.6 ± 24.6 yr; Gender: males = 203, females = 218

Triage: Australasian Triage Scale (ATS)

• Among those who contacted their GP (25%), they were advised to go to ED (73%)

• GP was closed (29%)

• Felt sick enough to require ED care (32%)

(Unwin, Kinsman et al. 2016) [51]

Australia

Cross-sectional survey

N = 477

NIH = 6

Age: < 25 yr = 217, > 25 yr = 260; Gender: males = 224, females = 253

Triage: Australian Triage Score (ATS)

• It was clearly an emergency to me (37.1%)

• Patient may need to have tests (such as x-rays and/or blood tests) (40.3%)

• ED more available than GP or other health care service (28.7%)

• GP not available (35.8%)

• Patient was told to go to ED by a doctor or nurse (28.9%)

• A health help line indicated the patient should attend (5.0%)

• It was related to a recent hospital contact or procedure (5.7%)

• Other services are too expensive (6.9%)

• The patient uses the ED for all their health concerns (2.1%)

• Did not know where else to go (9.2%)

• Other (6.9%)

(Wang, Tchopev et al. 2015) [52]

USA

Cross-sectional survey

N = 2711

NIH = 6

Female mean age (N = 1746): 26.7 ± 17.5 yr; Male mean age (N = 965): 19.9 ± 19.6 yr

Triage: Not specified

Health care service delivery issues:

• Access (11.0%)

• Primary care provider unavailable (44.9%)

Population behaviour issues

• Dissatisfaction with primary care provider (0.6%)

• Medication needs (0.2%)

• Unaware of primary care provider (0.8%)

• Usual place of care (0.3%)

Unavoidable ED visits

• Acute conditions (38.2%)

• Referral by primary care provider (4.1%)

(Young, Wagner et al. 1996) [54]

USA

Cross-sectional survey

N = 6187

NIH = 6

Median age: 31 yr, < 18 yr = 24%; Gender: males = 3046, females = 3141

Triage: Not specified (non-urgent patients determined to be those who came to ED but were 1) routed to an adjacent fast track unit, 2) rerouted to an urgent care clinic nearby, or 3) those refused care and were turned away after triage)

• Emergent or urgent condition (39%)

• Told to go to ED by clinician (19%)

• Too sick to go elsewhere (6%)

• Get good care in the ED (11%)

• Get diagnosis and/or treatment (11%)

• Barriers to receiving care elsewhere (65%)

• Clinic not open at night/not get off work (11%)

• Nowhere else to go for care (11%)

• Geographical reasons (8%)

• Tried to get care elsewhere (4%)

• Transportation problems (3%)

• Clinic does not take walk-in patients (3%)

• No money or insurance (8%)

• Free or low-cost ED care (4%)

• Insurance or work requirement (2%)

• Insurance pays for ED care (1%)

(Baskin, Baker et al. 2015) [22]

USA

Cross-sectional survey

N = 59

NIH = 5

Mean age: 43.5 ± 14.8 yr (18–91 yr); Gender: Not reported

Triage: Not specified

Percentage of sample that agreed with the statement:

• Sought treatment from a health care provider before accessing ED services (20%)

• Too worried about problem (97%)

• ED is the right place to go for problem (90%)

• Medical emergency (85%)

• Too sick/injured to go elsewhere (85%)

• In too much pain (85%)

• ES is closest/easiest place (81%)

• No appointment necessary (76%)

• Everything can be done at one place (49%)

• No place other than ED (48%)

• Regular care at this hospital (41%)

• They have no insurance (39%)

• Cannot afford other places (36%)

• Their medical record is there (32%)

• Family/friend told me to come (19%)

• Like environment of the ED (10%)

• ED is only place open (3%)

• Other places don’t take my insurance (3%)

• Better medical care here (3%)

• Need prescriptions refilled (3%)

(Bahadori, Mousavi et al. 2019) [19]

Iran

Cross-sectional survey administered via structured interview

N = 1217

NIH = 5

Age: < 49 yr = 777, > 49 yr = 440; Gender: males = 675, females = 542

Triage: Canadian Triage and Acuity Scale (CTAS)

• Proximity (8.5%)

• Closure of other centres or offices (3.2%)

• Being referred by a clinic or a physician’s office (8.4%)

• Having medical records in this hospital (29.5%)

• Perceived urgent problems/urgency of the problem (5%)

• Receiving better-off quality care (3.4%)

• Dissatisfaction with the clinic or physicians’ offices (2%)

• Receiving prompt care (36.6%)

• Seeking lower costs and cheaper care (36%)

• Transported by EMS ambulances (0.3%)

• Being an employee at hospital (patient or family member) (1.8%)

• No reasons provided (1.4%)

• Others (4.8%)

(Becker, Dell et al. 2012) [74]

South Africa

Cross-Sectional: Questionnaire by Masso et al. 2010

N = 277

NIH = 5

Mean age: 31.5 yr; Gender: males = 122, females = 155

Triage: South African Triage Score

The common self-reported reasons for attending the ED were:

• the clinic medicine was not helping (27.5%)

• a perception that the treatment at the hospital was superior to that at the clinic (23.7%)

• lack of a primary health clinic service after-hours in a specific geographical location (22%)

• too-long clinic waiting times (14%); (v) patients being referred to the EC (12.3%)

• that patients could have ‘special tests’ at the hospital (11.9%)

(Bianco, Pileggi et al. 2003) [23]

Italy

Cross-sectional Survey

N = 106

NIH = 5

Mean age: 50.6 yr (15–98 yr); Gender: males = 44, females = 62

Triage: Not specified (four-level system with a list of explicit criteria created a priori for this study)

• Most frequent reason stated for the visit was that they believed it was an emergency; more frequently indicated by patients judged to be presenting with non-urgent conditions (91%) compared with other patients (81.3%)

(Brasseur, Gilbert et al. 2021) [65]

Belgium

Cross-sectional survey

N = 1326

NIH = 5

Mean age: 39.8 ± 24.55 yr; Gender: males = 970, females = 975

Triage: ELISA Scale

• Suitability: ED appropriate for current problem (51.3%)

• Accessibility: Easily accessible (23.8%)

• Reputation: Felt confident about being cared for in the ED/ Felt specialized care was needed or because patient was being followed by a specific service from this hospital (4.6%)

• Because of the stress (4.2%)

• Financial concerns (0.8%)

• Others (15.3%)

(Brim 2008) [24]

United States

Cross-sectional survey

N = 64

NIH = 5

Mean age: 36 yr (18 – 76 yr); Gender: males = 24, females = 40

Triage: Not specified (“non-urgent” patients defined as requiring minimal procedures, medications or treatments, having minimal to no alteration in vital signs, and can wait without compromise)

Open-ended question – any comments you would like to make about the reason you selected the ED for your care today? (N = 33):

• Lack of providers open to publicly insured or uninsured participants (N = 9)

• Long waiting times for appointments (N = 8)

• Need for help (N = 6)

• Sense of urgency for care (N = 8)

(Faulkner and Law 2015) [28]

Australia

Quantitative/Qualitative—Telephone interviews with open and closed-ended questions

N = 58

NIH = 5

Age: 65–74 yr = 35, 75–89 yr = 20, 90 +  = 3; Gender: males = 27, females = 31

Triage: Australian Institute for Health and Welfare (AIHW)

• Condition was serious and needed urgent attention (29.1%)

• Only place open (17.1%)

• GP sent me to ED (12.8%)

• Was the weekend (10.3%)

• Could not get into local GP (6.0%)

• ED has more facilities (8.5%)

• Other (16.2%)

(Graham, Kwok et al. 2009) [78]

Hong Kong

Cross-sectional survey administered via structured interview

N = 249

NIH = 5

Mean age: 44 ± 18 yr; Gender: males = 126, females = 123

Triage: Hospital Authority of Hong Kong, Accident and Emergency Department Triage Guidelines

• Desire for more detailed investigations (56%)

• Perception that more professional medical advice would be given in ED (35%)

• Patient currently under continuing care at same hospital (19%)

• Direct referral from other health care professional (11%)

• Do not need to pay a fee (1.2%)

Unaware of availability of general outpatient clinics (5.7%)

(Hunt, DeHart et al. 1996) [58]

USA

Cross-Sectional Survey

N = 1547

NIH = 5

Mean age: Not Reported; Gender: Not Reported

Triage: Not specified (patient severity determined by the physician after they had been assessed and treated)

Columbia Grand Strand Regional Medical Center (tourist community) – 6 most frequent reasons (N = 557):

• I’m from out of town and just looked for the nearest emergency room. (23.0%)

• Don’t have a doctor/clinic that regularly takes care of me. (21.7%)

• Don’t have to make an appointment at the emergency room. (20.1%)

• Better medical care here than other places. (15.7%)

• My problem is bigger than my regular doctor/clinic could take care of. (14.6%)

• My doctor/clinic told me to come to the emergency department when the office is closed. (12.0%)

Pitt County Memorial Hospital (training program) – 6 most frequency reasons (N = 990):

• Don’t have a doctor/clinic that regularly takes care of me. (15.6%)

• Better medical care than places. (14.3%)

• Don’t have to make an appointment at the emergency room. (12.7%)

• My doctor/clinic told me to come to the emergency department when the office is closed. (11.0%)

• My doctor couldn’t see me soon enough. (7.6%)

• My problem is bigger than my regular/clinic could take care of. (7.1%)

(Laffoy, O'Herlihy et al. 1997) [34]

Ireland

Cross-Sectional: Structured interview questionnaires

N = 557

NIH = 5

Age: 0–15 yr = 10, 15–44 yr = 367, 45–74 yr = 128, 75 +  = 30; Gender: not reported

Triage: Not specified

• Thought I needed immediate attention (35.4%)

• Thought I needed an X-ray (18.2%)

• Hospital is convenient (13.7%)

• Thought GP would refer me anyway (7.6%)

• I prefer hospital for this condition (7.1%)

• I’m under hospital care already (5.6%)

• Hospital cheaper than GP (0.8%)

• GP told me to go to ED (0.3%)

• Other (14.4%)

(Müller, Winterhalder et al. 2012) [77]

Switzerland

Cross-Sectional Survey

N = 200

NIH = 5

Mean age: 35.5 yr (15–83 yr); Gender: males = 129, females = 71

Triage: Not specified

• Didn’t want to disturb GP (2.5%)

• ED can help better (14.0%)

• ED has better infrastructure (14%)

• GP is too far away (9%)

• I couldn’t reach the GP (15%)

• I have no GP (10.5%)

• Low confidence in GP (2.5%)

• Other (12%)

(Rassin, Nasie et al. 2006) [83]

Israel

Cross-sectional survey

N = 73

NIH = 5

Mean age: 39.4 yr (18–82 yr); Gender: males = 44, females = 29

Triage: Not specified

• Recommendation of a family member (68.6%)

• Quality of ED greater than primary care (62.9%)

• Geographical proximity to their home (47.2%)

• Usually when they feel sick they go to the ED (43%)

(Walsh 1995) [61]

UK

Qualitative and Quantitative: Structured interviews

N = 200

NIH = 5

Age range: 16–60 yr;

Gender: males = 100, females = 100

Triage: Not specified (non-urgent patients defined by presentation to “minor injury” section of an ED)

• ED more appropriate or better than GP (20%)

• GP would send me here anyway (17%)

• Quicker/wait too long for GP appointment (17%)

• Sent by GP after initially going to GP (14.5%)

• Advised to go to ED by others than GP (13.5%)

• More convenient than GP (11.5%)

• GP not available (10.5%)

• No GP or GP > 25 miles away (9%)

• Other (2%)

(Porro, Monzani et al. 2013) [82]

Italy

Cross-sectional survey administered via structured interview

N = 583

NIH = 4

Age: Not reported; Gender: Not reported

Triage: Not specified (patients categorized by “appropriateness:” 1) appropriate (i.e., sudden health problem, 2) inappropriate (i.e., long-standing problem), 3) hybrid (i.e., long-standing problem that suddenly re-emerged/worsened))

• Possibility to obtain all necessary examination at the same time (N = 232)

• Fastest solution for complaint (N = 187)

• Closest solution (N = 169)

• Suggested by a pharmacist (N = 99)

• Could not wait for family doctor visiting hours (N = 97)

• Suggested by relatives/friends (N = 60)

• Cheapest solution (N = 12)

(Rajpar, Smith et al. 2000) [44]

UK

Semi-structured questionnaire completed via interviews

N = 102 (N = 54 ED only)

NIH = 4

ED Patients: Mean age: 27.9 yr; Gender: males = 26, females = 28

Triage: Not specified (patients with primary care problems were defined as “those with non-emergency problems that could be managed in an average local GP surgery and triaged not to require treatment within two hours”)

• Stated “GP was closed” (50.0%)

• Perceived severity of problem (22.2%)

• Did not want to disturb their GP (11.1%)

• Wanted second opinion (7.4%)

• Perceived wait time in ED shorter than at GP (5.6%)

• Perceived that facility and investigations better at ED (3.7%)

(Rieffe, Oosterveld et al. 1999) [84]

Netherlands

Cross-sectional questionnaire

N = 430

NIH = 4

Mean age: 31.0 ± 15.1 yr; Gender: males = 280, females = 150

Triage: Not specified (no-urgent patients determined by whether their condition lasted > 24 h, and according to a classification scheme created by ED experts and applied by a medical student)

• 21 Motive Scales evaluating 63 different reasons for ED attendance (proportion of patients responding not reported, only mean scores); overall, motives primarily related to financial means and/or the preference of the expertise and facilities of ED

(Thomson, Kohli et al. 1995) [60]

UK

Cross-Sectional Survey

N = 245

NIH = 4

Mean age: 28.5 yr; Gender: males = 162, females = 83

Triage: Not specified (non-urgent patients determined to “not require immediate attention by a physician and could wait as necessary” and who had attended the ED without previously contacted their GP)

• Easier geographical access (15%)

• Convenience-related to timing (24%)

• GPs perceived inability to treat disorder (59%)

• Other (3%)

(Galanis, Siskou et al. 2019) [62]

Greece

Cross-sectional survey

N = 307

NIH = 2

Mean age: 50.4 yr ± 19.8 yr; Gender: not reported

Triage: Hospital Urgencies Appropriateness Protocol (HUAP)

• Patients had more confidence in hospital rather than primary care services/patients expected better care in EDs (46.6%)

• Patients’ residence was closer to the hospital (44.6%)

• Patients needed diagnostic tests (X-rays, laboratory tests, etc.) (31.6%)

• Patients were not aware whether an out-of-hospital emergency health service was at their disposal or its contact details (telephone number or address) (27%)

• Long waiting lists for hospital outpatient consultation (20.8%)

• Long waiting lists for appointments with non-hospital specialists (19.2%)

• Long waiting lists for primary care consultation (with contracted physicians or in health centers) (16.9%)

• Patients’ family prompted them to the EDs (16.9%)

• No primary care physician had been assigned to the patient (e.g., family doctor) (16.3%)

• Lack of a (primary care) physician in the public health system (14.3%)

• Inability to contact primary care services (13%)

• Patient did not trust their primary care physician (10.1%)