Table 1. Braun and Clarke’s 13 phases of thematic analysis, as adapted by Cooper et al. 15
Phase
|
|
Action
|
1
|
Familiarizing yourself with the data
|
• Each included study re-read following the quality appraisal
process
• A summary of each study and its key findings extracted and
displayed in a table (Table 2-3)
|
2
|
Generating initial codes
|
• Initial codes generated from display table
|
3
|
Searching for themes
|
• Looked for similarities of concepts within codes
• Grouped codes together into initial themes
|
4
|
Reviewing themes
|
• Compared and contrasted initial themes for similarities
• Re-coding
• Discussion of themes by researchers
|
5
|
Defining and naming themes
|
• Essence of each theme identified
• Detailed analysis of each theme written
• Reflected upon themes against study aims
• Scope of each theme determined
|
6
|
Producing the report
|
• Findings written up with supporting evidence of themes within the data
|
Table 2. Study and sample characteristics, primary aim/objective, and key themes/identified reasons for emergency department use among qualitative studies
Study Characteristics
Data Collection
Sample Size
|
Sample Characteristics
Triage Method
|
Stated Aim/Objective
|
Key Themes/Issues Identified for Reasons for Use
|
(Agarwal, Banerjee et al. 2012)
UK
Qualitative: Semi-structured Interviews
N=23
|
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: Based on the initial assessment
by an experienced consultant in the ED to identify patients suitable to be cared for in an alternative service including primary care
|
To explore the reasons for attendance at the ED by patients who could have been managed in an alternative service
|
• 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 |
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Benger and Jones 2008) </p>
<p>UK</p>
<p>Qualitative, semi structured questionnaire</p>
<p>N=200</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 58 yr (16-91 yr); Gender: males=96, females=104</p>
<p>104 patients (52%).<br> Triage: Not Reported; however, authors excluded “triage category 1”</p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To examine the</p>
<p>reasons for the various actions taken and the</p>
<p>outcome of these actions, to examine the extent to which patient behaviour and referral pathways may be contributing to increased ED attendances</p>
<p>and hospital admissions.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>Top five reasons why patients choose to attend ED (N=57):</p>
<p>• Perceived severity or urgency of their condition (51%)</p>
<p>• Previous experience (12%)</p>
<p>• Ease and convenience (7%)</p>
<p>• Housebound (7%)</p>
<p>• Primary care services are not available out of hours (7%)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Bornais, Crawley et al. 2020)</p>
<p>Canada</p>
<p>Qualitative Study, Semi-structured Interview</p>
<p>N=33 (30 patients, 3 caregivers)</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 40.3±17.3 yr (19 to 72 yr); Gender: males=12, females=21.</p>
<p>Triage: Included patients determined by an ED nurse as “non-urgent” (not otherwise defined).</p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To explore the reasons for patients and/or caregivers visiting the ED for non-urgent health conditions […] and to explore the barriers experienced by patients and/or caregivers when seeking access to health care for their health conditions.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Practitioner referral</p>
<p>• Primary care provider was contacted first but referred to ED instead for care (N=12)</p>
<p>• Efficacy of care (N=16)</p>
<p>• Everything “needed” is in one spot</p>
<p>• Leave with an answer</p>
<p>• Access to specialists</p>
<p>• Time Saver (N=26)</p>
<p>• Waiting for primary care provider could take days/weeks</p>
<p>• All testing done same day</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Claver 2011)</p>
<p>United States</p>
<p>Qualitative Study,</p>
<p>Semi-structured interviews</p>
<p>N=30</p>
<p> </p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 79.3±8.2 yr (56 to 92 yr); Gender: males=30, females=0.</p>
<p>Triage: Not reported.</p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To understand the process by which veteran ER users decide to visit the ER, and the role of social support networks</p>
<p>in the decision-making process.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• <em>Illness Burden</em> - 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</p>
<p>• <em>Knowledge</em> – influenced by knowledge about the course of their chronic illness and acute flare-ups, past experience with ER and potential care ER could provide</p>
<p>• <em>Insufficient self-care</em> – attempts at self-care/treatment at home is not working, most spoke of a wait-and-see method </p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Durand, Palazzolo et al. 2012)<br> France</p>
<p>Qualitative: Semi-structured interviews</p>
<p>N=87</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 38.3 yr ± 16.2 yr (17-78); Gender: males=47, females=40.</p>
<p>Triage: Determined by the nurse whether the presenting complaint could be taken care of by a primary care physician (non-urgent) or not (urgent)</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To explore the reasons why people with non-urgent complaints choose to come to EDs, and how ED health professionals perceive the phenomenon of “non-urgency”.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Fulfil health care needs (35.6%) and anxiety generated by the complaint (29.9%), as well as to relieve pain</p>
<p>• Barriers to primary care providers (e.g., difficulty obtaining appointment, difficulty accommodating their work schedules, understood options and alternatives and made choice)</p>
<p>• Advantages of the ED (e.g., availability of resources, diagnostic tests and treatment, availability of availability of medication, cared for in a single location)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Long, Knowles et al. 2021)</p>
<p>UK</p>
<p>Qualitative interviews</p>
<p>N=16 (N=8 for ED)</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 25 yr (18-30 yr); Gender: males=5, females=11.</p>
<p>Triage: 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.</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To present and discuss the findings relating to young adults’ decision making when seeking ‘clinically unnecessary’ care from the emergency ambulance service, ED or an urgent GP appointment.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>Results are pooled for all three settings (i.e., ED results not stratified)</p>
<p>• <em>Concern about the seriousness of symptoms and desire for reassurance</em> – feelings of anxiety and unfamiliarity were large triggers for both psychological and physical symptoms</p>
<p>• <em>Reduced coping capacity due to poor mental health, stress, lack of resources</em> – need for immediate relief (especially for pain), inability to cope due to stressful lives</p>
<p>• <em>Influence of others</em> – influence of others in social networks, perceptions or prior experiences of services (other peoples)</p>
<p>• <em>Concern about the impact of symptoms on daily life</em> – concerned, unable to access GP quickly enough</p>
<p>• <em>Positive and negative views of different services</em> </p>
<p>• <em>Frustration at lack of resolution of an on-going problem, despite previous efforts –</em> waiting long enough for things to improve/resolve</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Gomide MF 2012)</p>
<p>Brazil</p>
<p>Qualitative: interviews</p>
<p>N=23</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 40 yr; Gender: males=10, females=13.</p>
<p>Triage: Not specified.</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To identify why people use emergency care for non-urgent situations </p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Difficulty getting immediate care at other services</p>
<p>• Limited hours of primary care</p>
<p>• Limited time to primary care due to work obligations</p>
<p>• EDs have more diagnostic resources</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Goodridge and Stempien 2019)</p>
<p>Canada</p>
<p>Qualitative Study, Semi-structured interviews</p>
<p>N=115 (family member accompanied participant in 72 cases)</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 79.1 yr (65-98 yr); Gender: males=47, females=68.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with levels 4 (less-urgent) and 5 (non-urgent).</p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To describe older adults’ (65+ yr) understanding, expectations of, and self-reported reasons for seeking care and treatment provided in the ED.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Referred by GP or specialist (N=36)</p>
<p>• GP was not available (N=3)</p>
<p>• <em>Accessibility</em> - 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</p>
<p>• <em>Availability</em> – Only option after business hours</p>
<p>• <em>Quality of Care</em> – 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)</p>
<p>• <em>Previous Experience</em> – having tried to access primary care first in the past and being referred to ED influenced decision</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Guttman, Zimmerman et al. 2003)<br> USA</p>
<p>Structured interview with open-ended questions </p>
<p>N=77 </p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Age: 19-25 yr=11, 26-35 yr=22, 36-45 yr=12, 46-55 yr=8; Gender: males=41, females=36.</p>
<p>Triage: Considered “non-urgent” by ED triage staff.</p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To identify reasons for medically non-urgent ED visits from the users’ perspective.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Conceptions of needs (e.g., relief of pain/discomfort, reassurance, approval/second opinion, treatment, advice, financial)</p>
<p>• Conceptions of appropriateness (e.g., causing concern, after-hours services, unavailability/issues with primary care)</p>
<p>• Preference (e.g., geographical proximity, familiarity, trust, shorter wait, resources/facilities/staff availability, one-stop)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Henninger, Spencer et al. 2019)</p>
<p>Switzerland</p>
<p>Qualitative, Semi-structured interviews</p>
<p>N=20 (GP: N=9; ED: N=11)</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 44.2±34.6 yr (19 to 82 yr); Gender: males=9, females=11</p>
<p>Triage: Swiss Emergency Triage Scale (SETS); included patients with lowest degree of emergency based on SETS.</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>Identify the personal reasons why, when faced with a medical problem they perceive as urgent, they choose a GP or ED.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>Factors influencing decision where to consult (GP or ED):</p>
<p>• <em>Relationship with GP</em> - Those with strong relationships/trust in GP went first to GP, patients liked continuity of care offered by GP</p>
<p>• <em>Perceived nature of the complaint - </em>Chest pain and severe headaches were reason to consult ED</p>
<p>• <em>Anticipated wait time before being seen</em> - 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</p>
<p>Strong themes in favour of attending ED:</p>
<p>• Technical equipment (e.g., radiology)</p>
<p>• Open hours (24/7)</p>
<p>• Access to specialists</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Howard, Davis et al. 2005)<br> USA</p>
<p>Qualitative: Structured interview with open-ended questions</p>
<p>N=31</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 34 yr (22-43 yr); Gender: not reported.</p>
<p>Triage: “Non-urgent” status determined by chief complaint or diagnosis according to standards set by Kentucky Emergency Nurses Association.</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>Why do people choose to come to the ED instead of their primary care provider with non-urgent medical complaints?</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• 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)</p>
<p>• They were referred by the staff (not the doctor) in PCP’s offices to be evaluated in the ED</p>
<p>• 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</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Keizer Beache and Guell 2016)</p>
<p>St Vincent and the Grenadines, Caribbean</p>
<p>Grounded theory approach: Semi-structured interviews</p>
<p>N=12</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Age: 19-72 yr; Gender: males=7, females=5.</p>
<p>Triage: “Non-urgent” status determined by triage nurse.</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To explore the attitudes</p>
<p>that influence the decision-making of the Vincentian non-urgent accident and ED patients.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• 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)</p>
<p>• 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)</p>
<p>• 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)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Koziol-McLain, Price et al. 2000)</p>
<p>USA</p>
<p>Narrative Descriptive Design: Unstructured interviews</p>
<p>N=30</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 31 yr (17-60 yr); Gender: males=8, females=22.</p>
<p>Triage: 4-level triage system from 1 (life-threatening) to 4; patients included if triage level 2-4.</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To gain an understanding of the context in which patients choose to seek health care in an ED.</p>
<p> </p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Toughing it out (i.e., dealing with the issue before going to ED)</p>
<p>• Symptoms overwhelming self-care measures (i.e., use of over-the-counter medicines not working, medical issue impacts functioning)</p>
<p>• Calling a friend (i.e., social support/advice from friends, relatives, particularly maternal figure)</p>
<p>• Nowhere else to go (i.e., could not access alternative medical services, referred to ED by other healthcare providers)</p>
<p>• Convenience (i.e., work schedules, child care, transportation)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Kraaijvanger, Rijpsma et al. 2017)</p>
<p>Netherlands</p>
<p>Qualitative Study, Structured interview</p>
<p>N=30</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 46 yr; Gender: males=19, females=11.</p>
<p>Triage: Manchester Triage System; included patients who were orange (n=3), yellow (n=10), and green (n=17).</p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To explore what motives patients have to self-refer to an ED.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>Health Concerns</p>
<p>• Anxiety about presenting symptoms and consequences of being left untreated</p>
<p>• Expecting to need secondary care and wanted access to additional investigations/testing/treatment that are not provided by GP</p>
<p>• Receiving treatment in hospital for the presenting condition already</p>
<p>Practical Issues</p>
<p>• Perceived easier accessibility of the ED (no appointments needed, always accessible, no restrictions, more timely appointments than waiting for GP)</p>
<p>• Distance – not from the area and unfamiliar with where else to access care. Others from the area were closer to ED</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Matifary, Wachira et al. 2021)</p>
<p>Kenya</p>
<p>Qualitative Study, Semi-structured interviews</p>
<p>N=24</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 31.8±8.8 yr (25 to 55 yr); Gender: males=12, females=12.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with levels 4 (less-urgent) and 5 (non-urgent).</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To establish why adult patients with non-urgent medical conditions visit the ED in a tertiary university hospital in Kenya.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Feel unwell, want answers to why they are feeling unwell</p>
<p>• Positive experience in the past (efficient care, satisfied with services provided and quality of care)</p>
<p>• Other services closed</p>
<p>• Influenced by media in the form of advertisements</p>
<p>Some participants just needed a way to access care</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(McKenna, Rogers et al. 2020)<br> UK</p>
<p>Semi-structured interviews, social network mapping</p>
<p>N=40 (Demographics N=34)</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Age: 20-40 yr =14; 40-60 yr=11, 60-80 yr=8, >80 yr=1; Gender: males=14, females=20.</p>
<p>Triage: Not reported; included all participants triaged on arrival as “non-emergency.”</p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To map the personal networks of people attending ED for minor illness and injury in order to describe and explore their decision making around help-seeking.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p><em>System drivers of ED attendance:</em></p>
<p>• Inner circle of close relational ties did not greatly influence decision</p>
<p>• 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</p>
<p>• Presence of a network member with authority and expertise often helped to reinforce the purpose of ED and push toward primary care</p>
<p><em> </em></p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Palmer, Jones et al. 2005)</p>
<p>UK </p>
<p>Qualitative: Semi-structured telephone interviews</p>
<p>N=321</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 36.6±20.0 yr; Gender: males=176, females=145.</p>
<p>Triage: Manchester Triage System (MTS); included patients with MTS scores 4 or 5 (“inappropriate” or “walking-wounded”)</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To investigate why and how patients decide to attend ED and to assess their satisfaction with the experience </p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• AED more appropriate than GP (38.3%)</p>
<p>• GP would send me anyway (17.5%)</p>
<p>• Referred by GP (22.4%)</p>
<p>• Advised by others than GP (13.1%)</p>
<p>• Quicker, wait too long for GP appointment (23.4%)</p>
<p>• More convenient than GP (15.3%)</p>
<p>• GP surgery closed/not available (30.5%)</p>
<p>• No GP/GP more than 25 miles away (14.6%)</p>
<p>• Already tried GP without good outcome (4.7%)</p>
<p>• Other (1.6%)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Pförringer, Pflüger et al. 2021)</p>
<p>Germany</p>
<p>Qualitative, interview for open-ended questionnaire</p>
<p>N=235</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Age: <30 yr=88, 30-49 yr=69, 50-67 yr=49, >67 yr=29; Gender: males=125, females=110.</p>
<p>Triage: Guidelines of the German Society of Traumatology; type of patients included not specified.</p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To evaluate the motivation of those seeking ER treatment and to describe reasons for favouring ER treatment over primary care in relation to socioeconomic factors.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>Descriptive statistics were used to gain quantitative statements:</p>
<p>• Immediate help (45.9%)</p>
<p>• Fast treatment by a specialist (35.4%)</p>
<p>• Broad diagnostic tools (22.8%)</p>
<p>• High quality treatment (17.9%)</p>
<p>• Family doctor closed (12.6%)</p>
<p>• Other (17.9%)</p>
<p>• Fast admission to hospital (9.3%)</p>
<p>• Attestation (5.7%)</p>
<p>• Family doctor on holiday (4.4%)</p>
<p>• Blood analysis (4.4%)</p>
<p>• Free medication (3.3%)</p>
<p>• Thorough consultation (2.8%)</p>
<p>• Shorter waiting time (2.4%)</p>
<p>Replacement of family doctor unknown (1.2%)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Read, Varughese et al. 2014)</p>
<p>Quatar</p>
<p>Qualitative: Semi-structured interviews</p>
<p>N=100</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 33 yr; Gender: females=100.<br> Triage: Non-urgent ED females classified with low-acuity conditions, excluding minor trauma and lacerations.</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To understand why female patients with low-acuity conditions choose the emergency department over other healthcare options.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• Directed by employer to attend ED (40%) </p>
<p>• Advised to come by family (35%)</p>
<p>• Faster care and accessibility (98%)</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(Shaw, Howard et al. 2013)</p>
<p>USA</p>
<p>Qualitative: Semi-structured Interviews</p>
<p>N=30</p>
</td>
<td valign="top" width="26.874115983026876%">
<p>Mean age: 40 yr (21-63 yr); Gender: males=18, females=12.</p>
<p>Triage: Based on Emergency Severity Index (ESI); included levels 4-5 only (i.e., non-urgent).</p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To explore the complexity of patients’ decision- making process to use the ED vs. primary care alternatives.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>• No knowledge of other primary care options</p>
<p>• Being instructed by a medical professional</p>
<p>• Facing access barriers to their regular source of care</p>
<p>• Perceiving racial issues with a primary care option</p>
<p>• Defining their health care need as an emergency that required ED services</p>
<p>• Facing transportation barriers to other primary care options</p>
</td>
</tr>
<tr>
<td valign="top" width="14.144271570014144%">
<p>(van der Linden, Lindeboom et al. 2014)</p>
<p>Netherlands</p>
<p>Observational: Structured interview by nurse</p>
<p>N=3028</p>
</td>
<td valign="top" width="26.874115983026876%">
<p><em>Self-Referred: </em>Mean age: 32.3±18.6 yr; Gender: males=1636, females=1392.</p>
<p>Triage: 5-level triage system; included patients with levels 1-3 “life-threatening, very urgent, or urgent” (N=1174) and levels 4-5 “standard or non-urgent” (N=1854). </p>
</td>
<td valign="top" width="16.973125884016973%">
<p>To examine ED use and assess the characteristics of self-referrals and</p>
<p>non-self-referrals, their need for hospital emergency care and self-referrals' motives for presenting at the ED.</p>
</td>
<td valign="top" width="42.00848656294201%">
<p>Among the self-referred patients, 1751 answered the question (58%):</p>
<p>• Accessibility and convenience</p>
<p>• Perceived medical necessity</p>
<p>• Not thought about going to the GP</p>
<p>• Not having a regular GP</p>
<p>• Familiarity</p>
<p>• Dissatisfaction with GP</p>
<p>• Referral by non-professionals</p>
<p>• Language barriers</p>
</td>
</tr>
</thead>
Note: AED= Accident and Emergency Room; ED= Emergency Department; ER= Emergency Room; GP=General Practitioner
Table 3. Study and sample characteristics, primary aim/objective, and key themes/identified reasons for emergency department use among quantitative studies
|
Study Characteristics
Data Collection Method
|
Sample Characteristics
Triage Methods
|
Stated Aim/Objective
|
Key Themes/Issues Identified for Reasons for Use
|
1.
|
(Afilalo, Guttman et al. 1995)
Canada
Cross-sectional survey administered via structured interview
N=849
(N=186 for Category II and III interviews)
|
Total sample: Age: <65=72.7%; Gender: males=418, females=431.
Triage: Three-level list of explicit criteria; included patients with category I (60.8%; can only be cared for in ED), II (24%; cared for in either ED or GP in less than 6 hr), and III (15.2%; cared for in either ED or GP in more than 6 hr).
|
To examine appropriate and inappropriate use of the ED.
|
• 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%) |
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>2. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Afilalo, Marinovich et al. 2004)</p>
<p>Canada </p>
<p>Observational: Secondary analysis of a prospective cross-sectional study</p>
<p>N=454</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 43.3±18.1 yr; Gender: males=224, females=230.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with CTAS 5 considered “non-urgent.”</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>Compare urgent, semi-urgent and non-urgent patients and non-urgent patients' reasons for not seeking care with a primary care physician before presenting to the ED. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Accessibility (30.1%)</p>
<p>• Perception of ED-specific need (22.1%)</p>
<p>• Referral/follow up to the ED (20.2%)</p>
<p>• Familiarity with the ED (11.1%)</p>
<p>• Trust of the ED (7.4%)</p>
<p>• No specific reason (7.1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>3. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Al-Otmy, Abduljabbar et al. 2020)</p>
<p>Saudi Arabia</p>
<p>Cross-sectional survey administered via structured interview</p>
<p>N=400 </p>
<p>(N=314 non-urgent)</p>
</td>
<td valign="top" width="20%">
<p><em>Total Sample: </em>Mean age: 50.3±19.7 yr (14-98 yr); Gender: males=181, females=219.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with levels 3 (urgent), 4 (less-urgent), and 5 (non-urgent).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To assess the magnitude of non-urgent visits to the ED and to identify factors associated with the non-urgent visits in Western Saudi Arabia.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>For those triaged as non-urgent (N=314)</p>
<p>• Participant felt their condition was urgent (41.1%)</p>
<p>• Easier accessibility (26.1%)</p>
<p>• Limited resources and services in the primary healthcare centre (19.4%)</p>
<p>• Difficulty getting an appointment (11.8%)</p>
<p>• Referred from primary healthcare centre to ED (3.5%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>4. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Alyasin and Douglas 2014)</p>
<p>Australia</p>
<p>Cross sectional survey</p>
<p>N=350</p>
<p> </p>
</td>
<td valign="top" width="20%">
<p>Mean age: 32.1±12.2 yr (18 to 80 yr); Gender: males=202, females=148.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with levels 3 (urgent), 4 (N=160; “less-urgent”), and 5 (N=190; “non-urgent”).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To examine the reasons for non-urgent visits to Saudi ED and factors associated with patient perceptions of urgency.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Do not have a regular healthcare provider (63.4%)</p>
<p>• Can receive care on the same day without an appointment (62.6%)</p>
<p>• Convenience and access to medical care 24/7 (62.6%)</p>
<p>• ED gives better care than other health services in the area (44.6%)</p>
<p>• Can access investigation such as blood tests/x-rays (37.4%)</p>
<p>Urgency of problem (22.3%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>5. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Amiel, Williams et al. 2014)<br> UK</p>
<p>Survey Questionnaire</p>
<p>N=649</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 35 yr (18-84 yr); Gender: males=266, females=383.</p>
<p>Triage: Nurse streams patients into one of four categories: “minor illness,” “minor injury,” “emergency for transfer,” or “see and treat.” Only “minor illness” patients were included.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To explore why patients with minor illness choose to attend an urgent care centre for their healthcare needs. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Quicker than a GP appointment (28%)</p>
<p>• Nearest place to home or work (23%)</p>
<p>• Best place for my particular problem (10%)</p>
<p>• Recommended by friends, family or colleague (10%)</p>
<p>• Thought there would be a shorter wait (8%)</p>
<p>• More confidence in advice than given by own GP (7%)</p>
<p>• Did not think about going anywhere else (6%)</p>
<p>• Did not have a GP to go elsewhere (3%)</p>
<p>• Wanted a second opinion (2%)</p>
<p>• Other (3%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>6. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Atenstaedt, Gregory et al. 2015)<br> UK</p>
<p>Cross-Sectional Survey</p>
<p>N=806</p>
</td>
<td valign="top" width="20%">
<p>Age: 0-15 yr=12%, 16-29 yr=27%, 30-69 yr=57%, 75+ yr=4%; Gender: males=459, females=347.</p>
<p>Triage: Manchester Triage System (included green-standard or blue-non-urgent patients only)</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To explore why non-urgent patients attend an ED despite alternative services</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Thought might need radiograph (46%)</p>
<p>• Did not think GP could help (29%)</p>
<p>• GP was not available (19%)</p>
<p>• Could be seen quicker at ED (11%)</p>
<p>• Thought might need to go to hospital (10%)</p>
<p>• Wanted to see specialist (9%)</p>
<p>• Thought might need stitches (6%)</p>
<p>• ED nearer than other service (6%)</p>
<p>• Was not aware of other services (3%)</p>
<p>• Does not have GP (3%)</p>
<p>• Did not want to bother GP (3%)</p>
<p>• Wanted a second opinion (3%)</p>
<p>• Thought might need tetanus shot (3%)</p>
<p>• ED is easier to get to than other service (2%)</p>
<p>• Dentist was not available (1%)</p>
<p>• Thought might need blood test (1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>7. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Baker, Stevens et al. 1995)<br> USA</p>
<p>Cross-sectional survey</p>
<p>N=1190</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 37 yr±14.0 yr; Gender: males=524, females=666.</p>
<p>Triage: Four-level triage system based on a list of explicit criteria. Unstable conditions were excluded. All patients emergent, urgent and non-urgent were included.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine emergency department patients' perceptions of their illness urgency, their attempts to</p>
<p>get care elsewhere, and the proportion of patients referred to the ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• 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%)</p>
<p>• Among 38% who did see their GP in the preceding week, 68% were referred to ED.</p>
<p>• Among all patients, 89% said that they needed to be seen immediately.</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>8. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Baskin, Baker et al. 2015)</p>
<p>USA</p>
<p>Cross-sectional survey </p>
<p>N=59</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 43.5±14.8 yr (18-91 yr); Gender: Not reported.</p>
<p>Triage: Unspecified triage system but included patients with level level 4 (non-urgent) or level 5 (minor) priorities.</p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To describe the factors that influence a rural persons’ decisions to seek care in the ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Percentage of sample that agreed with the statement:</p>
<p>• Sought treatment from a health care provider before accessing ED services (20%)</p>
<p>• Too worried about problem (97%)</p>
<p>• ED is the right place to go for problem (90%)</p>
<p>• Medical emergency (85%)</p>
<p>• Too sick/injured to go elsewhere (85%)</p>
<p>• In too much pain (85%)</p>
<p>• ES is closest/easiest place (81%)</p>
<p>• No appointment necessary (76%)</p>
<p>• Everything can be done at one place (49%)</p>
<p>• No place other than ED (48%)</p>
<p>• Regular care at this hospital (41%)</p>
<p>• They have no insurance (39%)</p>
<p>• Cannot afford other places (36%)</p>
<p>• Their medical record is there (32%)</p>
<p>• Family/friend told me to come (19%)</p>
<p>• Like environment of the ED (10%)</p>
<p>• ED is only place open (3%)</p>
<p>• Other places don’t take my insurance (3%)</p>
<p>• Better medical care here (3%)</p>
<p>• Need prescriptions refilled (3%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>9. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Burchard, Oikonomoulas et al. 2019)</p>
<p>Germany</p>
<p>Cross-sectional survey</p>
<p>N=499</p>
</td>
<td valign="top" width="20%">
<p>Median Age: 32 yr (IQR 50-22); Gender: males=300, females=199.</p>
<p>Triage: Manchester Triage System (MTS); included all patients level 4 (standard) or level 5 (non-urgent) based on MTS.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To evaluate reasons of patients <em>without </em>GP referral, admittance by ambulance, or a Manchester triage score below 4, for attending an ED instead of first going to their GP. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Deemed their medical condition something that needed urgent or emergency diagnosis and treatment (63.1%)</p>
<p>• A GP would be unable to treat their medical problem (74%)</p>
<p>• Expected a hospital admission or in-patient treatment was necessary (2.4%)</p>
<p>• Factors guiding decision (ED over GP):</p>
<p>• Technical equipment (3.5%)</p>
<p>• No GP (1.4%)</p>
<p>• 24/7 Access (4.3%)</p>
<p>• Negative experience (0.4%)</p>
<p>• Waiting experience (10.3%)</p>
<p>• I donot like to answer this question ( 80.1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>10. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Bahadori, Mousavi et al. 2019)</p>
<p>Iran</p>
<p>Cross-sectional survey administered via structured interview</p>
<p>N=1217</p>
</td>
<td valign="top" width="20%">
<p>Age: <49 yr=777, >49 yr=440; Gender: males=675, females=542.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included all patients of CTAS level 4 (less-urgent) and level 5 (non-urgent).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine the percentage of non-urgent</p>
<p>visits in an Iranian ED […] and to explore why patients with non-urgent conditions refer to EDs</p>
<p>and to assess the association between patients’ characteristics and their visits.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Proximity (8.5%)</p>
<p>• Closure of other centres or offices (3.2%)</p>
<p>• Being referred by a clinic or a physician’s office (8.4%)</p>
<p>• Having medical records in this hospital (29.5%)</p>
<p>• Perceived urgent problems/urgency of the problem (5%)</p>
<p>• Receiving better-off quality care (3.4%)</p>
<p>• Dissatisfaction with the clinic or physicians’ offices (2%)</p>
<p>• Receiving prompt care (36.6%)</p>
<p>• Seeking lower costs and cheaper care (36%)</p>
<p>• Transported by EMS ambulances (0.3%)</p>
<p>• Being an employee at hospital (patient or family member) (1.8%)</p>
<p>• No reasons provided (1.4%)</p>
<p>• Others (4.8%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>11. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Barbadoro, Di Tondo et al. 2015)</p>
<p>Italy</p>
<p>Cross sectional survey</p>
<p>N=61</p>
</td>
<td valign="top" width="20%">
<p>Age: 18-65 yr=52, ≥65=9; Gender: males=33, females=28.</p>
<p>Triage: Included “non-urgent” patients defined as having no active symptoms or they 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.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To analyze the variables associated to: (1) hospital readmission and (2) to ED utilization for non-urgent care in the area of interest.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Of the non-urgent participants (N=61), the following were present<u> </u>motivations for accessing ED:</p>
<p>• Urgency perceived by patient (N=23)</p>
<p>• Recent traumatic injury (N=14)</p>
<p>• Difficulty contacting GP (N=9)</p>
<p>• Greater confidence in the hospital (N=14)</p>
<p>• Previous medical therapy without benefit (N=10)</p>
<p>• Too long to book exams (N=20)</p>
<p>• ED has more tools to solve clinical problems (N=21)</p>
<p>• Easy accessibility of ED (N=5)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>12. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Becker, Dell et al. 2012)</p>
<p>South Africa</p>
<p>Cross-Sectional: Questionnaire by Masso et al. 2010</p>
<p>N=277</p>
<p> </p>
</td>
<td valign="top" width="20%">
<p>Mean age: 31.5 yr; Gender: males=122, females=155.</p>
<p>Triage: South African Triage Score (all green-routine care were included.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine patient-specific reasons for accessing ED for primary health care problems. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>The common self-reported reasons for attending the ED were: </p>
<p>• the clinic medicine was not helping (27.5%)</p>
<p>• a perception that the treatment at the hospital was superior to that at the clinic (23.7%) </p>
<p>• lack of a primary health clinic service after-hours in a specific geographical location (22%)</p>
<p>• too-long clinic waiting times (14%); (v) patients being referred to the EC (12.3%) </p>
<p>• that patients could have ‘special tests’ at the hospital (11.9%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>13. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Bianco, Pileggi et al. 2003)<br> Italy</p>
<p>Cross-sectional Survey</p>
<p>N=106</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 50.6 yr (15-98 yr); Gender: males=44, females=62.</p>
<p>Triage: Four-level system with a list of explicit criteria created <em>a priori</em> for this study; only patients meeting the criteria for urgent or non-urgent were included, not emergent or extreme emergency)</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The purpose of this study was to determine the extent of non-urgent visits and the effect of different characteristics on such visits to one public hospital ED located in Catanzaro, Italy.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• 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%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>14. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Brasseur, Gilbert et al. 2021)</p>
<p>Belgium</p>
<p>Cross-sectional survey</p>
<p>N=1326</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 39.8±24.55 yr; Gender: males=970, females=975.</p>
<p>Triage: ELISA Scale; included all “non-urgent” patients who self-referred.</p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine the drivers and rationale motivating walk-in patients to reach the ED rather than use primary care resources.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Suitability: ED appropriate for current problem (51.3%)</p>
<p>• Accessibility: Easily accessible (23.8%)</p>
<p>• 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%)</p>
<p>• Because of the stress (4.2%)</p>
<p>• Financial concerns (0.8%)</p>
<p>• Others (15.3%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>15. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Brim 2008)</p>
<p>United States</p>
<p>Cross-sectional survey</p>
<p>N=64</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 36 yr (18 – 76 yr); Gender: males=24, females=40.</p>
<p>Triage: Not reported; included “non-urgent” patients defined as requiring minimal procedures, medications or treatments, having minimal to no alteration in vital signs, and can wait without compromise.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate the reasons why people use an ED for non-urgent care during the hours when primary care providers are available.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Open-ended question – any comments you would like to make about the reason you selected the ED for your care today? (N=33):</p>
<p>• Lack of providers open to publicly insured or uninsured participants (N=9)</p>
<p>• Long waiting times for appointments (N=8)</p>
<p>• Need for help (N=6)</p>
<p>• Sense of urgency for care (N=8)</p>
<p> </p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>16. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Cheek, Allen et al. 2016)<br> Australia</p>
<p>Cross-sectional Survey</p>
<p>N=138</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 47±21.1 yr (18-87 yr); Gender: males=63, females=75.</p>
<p>Triage: Australian Institute of Health and Welfare (AIHW) – included patients with level 4 or 5 defined as “GP-type” presentations</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To identify factors associated with low-acuity use of ED amongst GP and self-referrals. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Questions listed on the survey verbatim:</p>
<p>• I am able to see the doctor and have any tests or x-rays all in the same place at the ED (71.7%)</p>
<p>• My GP surgery was closed (57.2%)</p>
<p>• I am not happy with the time I have to wait to acquire an appointment with a GP (34.8%)</p>
<p>• The ED is closer to home or work than the GP surgery (34.8%)</p>
<p>• I feel the medical treatment is better at the ED (32.6%)</p>
<p>• I thought the GP would send me to the ED anyway (31.2%)</p>
<p>• I have to wait too long to see the GP (29.7%)</p>
<p>• I do not see the same GP when I attend my GP practice (29.0%)</p>
<p>• My GP referred me to the Ed (16.7%)</p>
<p>• I find it difficult to understand my GP (15.9%)</p>
<p>• My family has traditionally used the Ed for our health care (15.9%)</p>
<p>• I did not think my GP had the required equipment (15.2%)</p>
<p>• I prefer the hospital environment to the GP surgery (14.5%)</p>
<p>• I do not like making appointments and prefer the ED as I can attend when I want (13.0%)</p>
<p>• I wanted to see a doctor I do not know (13.0%)</p>
<p>• I wanted a second opinion (10.9%)</p>
<p>• I am on holiday away from usual GP (2.9%)</p>
<p>• I did not want GP to know about this particular problem (1.4%)</p>
<p>• I preferred to see a female doctor and thought I could at the ED (0%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>17. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Coelho Rodrigues Dixe, Passadouro et al. 2018)</p>
<p>Portugal</p>
<p>Cross-sectional survey administered via structured interview</p>
<p>N=357</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 54.51±20.9 yr (18 to 92 yr); Gender: males=144, females=213.</p>
<p>Triage: Manchester Triage System (MTS); included all patients deemed “standard” or “non-urgent” based on MTS.</p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To assess the sociodemographic characteristics and ED use of non-urgent patients […] and to explore factors influencing use of ED by non-urgent patients.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Disease justified ED use (91.7%)</p>
<p>• Can undergo all medical examinations on same day (65.6%)</p>
<p>• Wanted to be examined by specialist (53.9%)</p>
<p>• Difficult to schedule an appointment at healthcare center (44.3%)</p>
<p>• Quicker to be examined at hospital (38.1%)</p>
<p>• Matter of habit (26.75%)</p>
<p>• Unsatisfied with healthcare center in similar situations (26.6%)</p>
<p>• Worsening of chronic disease during follow-up in outpatient visit (21.0%)</p>
<p>• Healthcare center closed, did not know where to go (20.7%)</p>
<p>• Doctor was not at the healthcare center, no alternative (16.4%)</p>
<p>• No vacancy at healthcare center, I had no alternative (15.7%)</p>
<p>• Visit hours at healthcare center weren’t compatible with work/school (15.4%)</p>
<p>• Closer to the hospital (15.4%)</p>
<p>• Don’t have family doctor (14.7%)</p>
<p>• Hoping to be hospitalized (5.4%)</p>
<p>• Have a private doctor, don’t usually use healthcare center (9.6%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>18. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Coleman, Irons et al. 2001)</p>
<p>UK</p>
<p>Cross-Sectional Survey</p>
<p>N=255</p>
</td>
<td valign="top" width="20%">
<p>Age: <35 yr=145, >35 yr=110; Gender: males=136, females=119.</p>
<p>Triage: Five-colour system (black, red, blue, green, yellow) with included patients either green (i.e., new illness or injury that is non-urgent) or yellow (i.e., long-standing issue).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To estimate the potential of alternate urgent care services to reduce non-urgent demands on ED departments.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Perceptions of seriousness (76%)</p>
<p>• Positive experiences at ED (70%)</p>
<p>• Seeking a specific service (68%)</p>
<p>• Awareness of other services (62%)</p>
<p>• Processes and patient’s time (56%)</p>
<p>• Advised to come by others (43%)</p>
<p>• Availability of other services (38%)</p>
<p>• Seeking assurance (38%)</p>
<p>• Convenience of access (24%)</p>
<p>• Patient preference (11%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>19. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Dawoud, Ahmad et al. 2015)</p>
<p>Saudi Arabia</p>
<p>Cross sectional study, </p>
<p>Interviewed with structured questionnaire</p>
<p>N=300</p>
</td>
<td valign="top" width="20%">
<p>Age: ≤15 yr= 80, 16-31 yr=105, 32-60 yr=93, >60 yr=22; Gender: males=152, females=148.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with level 5 (non-urgent) (53.0% of sample).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The aims of estimating emergency service utilization for non-urgent cases, identifying the</p>
<p>predictors of ER utilization for non-urgent cases, and measuring patients’ knowledge of primary healthcare</p>
<p>centers (PHCCs).</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Reasons why patients went to ER instead of primary healthcare center:</p>
<p>• Limited working hours (60.8%)</p>
<p>• Limited services and resources (60.4%)</p>
<p>• Mistrust of health centers (24.6%)</p>
<p>• Lack of experience among the medical staff (10.1%)</p>
<p>• Lack of knowledge of the health centers (7.1%)</p>
<p>• Dissatisfaction with the treatment provided (7.1%)</p>
<p>• Lack of effective diagnosis (6.3%)</p>
<p>Reason why patients went to ER despite having health insurance:</p>
<p>• Closest governmental hospital (69.8%)</p>
<p>• Other hospital does not receive some cases (44.4%)</p>
<p>• Congestion in other hospitals (14.3%)</p>
<p>• Insurance requirements have not yet been completed (12.7%)</p>
<p>• Trust the governments treatment more (4.8%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>20. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(de Valk, Taal et al. 2014)</p>
<p>Netherlands</p>
<p>Cross-Sectional Survey</p>
<p>N=436</p>
<p> </p>
</td>
<td valign="top" width="20%">
<p>Age: 18-35 yr=54, 35-65 yr, 65+=7; Gender: males=251, females=185.</p>
<p>Triage: Not reported; only included patients that “self-referred” to the ED.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine the</p>
<p>characteristics and motivations of self-referred patients (SRPs) at the ED. The secondary objective was to explore</p>
<p>SRPs’ opinion about copayments.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Belief that ED could provide care that the GP could not (28%)</p>
<p>• Specialist that patient sees already at that hospital (17%)</p>
<p>• There was not a GP nearby (16%)</p>
<p>• Could get help earlier at ED (15%)</p>
<p>• ED was located nearby (11%)</p>
<p>• Did not have a GP (11%)</p>
<p>• Could not contact the GP (7%)</p>
<p>• Unsure where to locate a GP (5%)</p>
<p>• Previous negative experience with GP (4%)</p>
<p>• No trust in GP (3%)</p>
<p>• Advised by others to go (3%)</p>
<p>• Belief the complaint was urgent (2%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>21. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Diserens, Egli et al. 2015)<br> Switzerland</p>
<p>Observational: Survey</p>
<p>N=516 (2000)</p>
<p>N=581 (2013)</p>
</td>
<td valign="top" width="20%">
<p><em>Sample from 2000: </em>Mean age: 46.4±22.0 yr; Gender: males=294, females=222. <br><em>Sample from 2013</em></p>
<p>Mean age: 44.5±20.0 yr; Gender: males=314, females=267.<br> Triage: Swiss Emergency Triage Scale (SETS); only included patients with SETS level 3 (non-life-threatening, to be seen in less than 2 hr or when physician available)</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To test if the characteristics of adult patients attending ED with non-life-threatening conditions changed over time between 2000 and 2013.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Reasons for Self-Referral to ED (2000 vs. 2013)</p>
<p>• Unawareness of alternatives for emergencies (12.5% vs. 5.4%)</p>
<p>• Excellence of the institution and access to specialists (9.8% vs. 3.8%)</p>
<p>• Usual place of consultation (6.7% vs. 4.1%)</p>
<p>• Easy access (3.4% vs. 5.2%)</p>
<p>• Dissatisfaction with treatment or appointment with GP (0.7% vs. 1.7%)</p>
<p>• Convenience of unscheduled appointment (0.5% vs. 1.7%)</p>
<p>• Paramedics choice (0.5% vs. 1.7%)</p>
<p>• Other (0.7% vs. 1.3%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>22. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Faulkner and Law 2015)<br> Australia</p>
<p>Quantitative/Qualitative - Telephone interviews with open and closed-ended questions</p>
<p>N=58</p>
</td>
<td valign="top" width="20%">
<p>Age: 65-74 yr=35, 75-89 yr=20, 90+=3; Gender: males=27, females=31.</p>
<p>Triage: Australian Institute for Health and Welfare – included only patients at levels 3-5 with “potentially avoidable GP-type presentations”</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To explore unnecessary use of EDs by older people.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Condition was serious and needed urgent attention (29.1%)</p>
<p>• Only place open (17.1%)</p>
<p>• GP sent me to ED (12.8%)</p>
<p>• Was the weekend (10.3%)</p>
<p>• Could not get into local GP (6.0%)</p>
<p>• ED has more facilities (8.5%)</p>
<p>• Other (16.2%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>23. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Field and Lantz 2006)</p>
<p>Canada</p>
<p>Cross-section survey</p>
<p>N=235</p>
</td>
<td valign="top" width="20%">
<p>Age: not reported; Gender: not reported.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included all patients of CTAS level 4 (“less-urgent”) and level 5 (non-urgent).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To study reasons for non-urgent ED use at a tertiary care ED in Nova Scotia and to determine how often the lack of a family physician was associated with non-urgent ED use.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Access to a specific service (49%)</p>
<p>• Obtain rapid treatment for a perceived urgent problem (43%)</p>
<p>• Limited access to family physician (23%)</p>
<p>• Referred to the ED (20%)</p>
<p>• Did not have a family physician (3%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>24. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Gentile, Vignally et al. 2010)</p>
<p>France</p>
<p>Cross-sectional survey</p>
<p>N=85</p>
<p> </p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="20%">
<p>Mean age: 36.3±11.7 yr (18-70 yr); Gender: males=50, females=35.</p>
<p>Triage: Included all patients deemed “non-urgent” by triage nurse.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To assess the willingness of non-urgent patients to be reoriented outside the ED to a primary care unit […] and to collect the reasons prompted them to accept/refuse.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Were unable to contact GP (33%) or trouble accessing their usual source of care (22.3%)</p>
<p>• Referrals: self (76%), GP (17.6%), for medico-legal reasons by employer/police (5.9%)</p>
<p>• Attending due to the pain (65.8%)</p>
<p>• Need for diagnostic investigations (37.6%)</p>
<p>• Needing consultation for traumatological problems</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>25. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Galanis, Siskou et al. 2019)</p>
<p>Greece</p>
<p>Cross-sectional survey</p>
<p>N=307</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 50.4 yr±19.8 yr; Gender: not reported.</p>
<p>Triage: Hospital Urgencies Appropriateness Protocol</p>
<p>(HUAP); included individuals deemed “inappropriate” according to the HUAP.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The aim of this study was to evaluate the appropriateness of use of the EDs and to</p>
<p>identify the respective reasons of inappropriate use.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Patients had more confidence in hospital rather than primary care services/patients expected better care in EDs (46.6%)</p>
<p>• Patients’ residence was closer to the hospital (44.6%)</p>
<p>• Patients needed diagnostic tests (X-rays, laboratory tests, etc.) (31.6%)</p>
<p>• 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%)</p>
<p>• Long waiting lists for hospital outpatient consultation (20.8%)</p>
<p>• Long waiting lists for appointments with non-hospital specialists (19.2%)</p>
<p>• Long waiting lists for primary care consultation (with contracted physicians or in health centers) (16.9%)</p>
<p>• Patients’ family prompted them to the EDs (16.9%)</p>
<p>• No primary care physician had been assigned to the patient (e.g., family doctor) (16.3%)</p>
<p>• Lack of a (primary care) physician in the public health system (14.3%)</p>
<p>• Inability to contact primary care services (13%)</p>
<p>• Patient did not trust their primary care physician (10.1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>26. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Ghazali, Richard et al. 2019)</p>
<p>France</p>
<p>Cross-sectional survey</p>
<p>N=598</p>
</td>
<td valign="top" width="20%">
<p>Median age: 38 yr (IQR 27-50); Gender: males=475, females=123.</p>
<p>Triage: French Emergency Nurses Classification in Hospital Scale, Classification Infirmière des Malades aux Urgences (CIMU); included all patients with CIMU level 5. </p>
<p> </p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To analyze the profiles, motivations, and post-ED consult satisfaction of patients not requiring ED consultation […] and to determine whether it is possible to redirect patients to a PCP before consulting with the emergency physician based on a potential initial triage error.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Expectation of getting hospital-based care, including access to further testing or hospitalization (N=171)</p>
<p>• Personal convenience (geographical proximity, opening hours) (N=147)</p>
<p>• Not having to pay for service (N=20)</p>
<p> </p>
<p>Motivations:</p>
<p>• Workplace accident (2.8%)</p>
<p>• Suggested by peers (0.5%)/professional (9.7%)</p>
<p>• Second opinion (3.6%)</p>
<p>• Intense pain (4.5%)</p>
<p>• Additional testing (26.3%)</p>
<p>• Appointment hours (1.3%)/After business hours (5.2%)</p>
<p>• Hospitalization (2.3%)</p>
<p>• Unavailable primary care provider (19.2%)</p>
<p>• Lack of upfront payment (3.7%)</p>
<p>• Geographic proximity (17.7%)</p>
<p>• Already taken care of in this hospital (3.2%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>27. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Gill and Riley 1996)</p>
<p>USA</p>
<p>Cross-Sectional: Structured interview</p>
<p>N=268 </p>
</td>
<td valign="top" width="20%">
<p>Age: 18-39 yr=138, 40-64 yr=54, 65+ yr=5; Gender: males=132, females=135, unknown=1.</p>
<p>Triage: Nonurgent patients were defined as those who “may safely wait several hours or more for evaluation.” </p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To examine ED patients’ perceptions of urgency and to determine whether patients with no regular source of medical care are more likely to use ED for nonurgent problems. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Reasons for attending ED (perceived urgency: urgent vs. non-urgent):</p>
<p>• Emergency department closer (33 vs. 39%)</p>
<p>• Emergency department faster (19 vs. 25%)</p>
<p>• No regular source of care (19% vs. 16%)</p>
<p>• Likes emergency department service (16% vs. 18%)</p>
<p>• Regular source of care not accessible (20% vs. 8%)</p>
<p>• Urgent problem (16% vs. 14%)</p>
<p>• Referred (11% vs. 16%)</p>
<p>• More convenient (11% vs. 12%)</p>
<p>• Financial (7% vs. 8%)</p>
<p>• Better medical care (6% vs. 6%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>28. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Graham, Kwok et al. 2009)</p>
<p>Hong Kong</p>
<p>Cross-sectional survey administered via structured interview</p>
<p>N=249</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 44±18 yr; Gender: males= 126, females=123.</p>
<p>Triage: Hospital Authority of Hong Kong, Accident and emergency department triage guidelines; included patients of level 4 (“semi-urgent”) or level 5 (“non-urgent”).</p>
<p> </p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To explore why patients seek advice and medical care from ED rather than other available sources of health care</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Desire for more detailed investigations (56%)</p>
<p>• Perception that more professional medical advice would be given in ED (35%)</p>
<p>• Patient currently under continuing care at same hospital (19%)</p>
<p>• Direct referral from other health care professional (11%)</p>
<p>• Do not need to pay a fee (1.2%)</p>
<p>Unaware of availability of general outpatient clinics (5.7%) </p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>29. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Han, Ospina et al. 2007)</p>
<p>Canada</p>
<p>Questionnaire by either interview or self-administered, open-ended questions</p>
<p>N=894</p>
<p>(N=421, 47% of CTAS 4-5)</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 44.1±19.7; Gender: males= 438, females=456.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included levels 2 (emergent), 3 (urgent), 4 (less-urgent), and 5 (non-urgent).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To examine the frequency and determinants</p>
<p>of patients’ efforts to access alternative care before ED […] and to explore patients’ perception of whether or not the ED was the best available care option.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Perceived severity of their health problems (<em>N</em>=230)</p>
<p>• Quality of care in the ED (<em>N</em>=185)</p>
<p>• Physician availability (N=137)</p>
<p>• Professional referral (<em>N=</em>100) </p>
<p>• Perceived rapidity of care in the ED (<em>N=</em>80). </p>
<p>• Felt it was only option (N=76)/No physician available (N=58)</p>
<p>• ED was convenient (N=71)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>30. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Hodgins and Wuest 2007)</p>
<p>Canada</p>
<p>Structured interviews</p>
<p>N=1612</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 43.0 yr (16-93 yr); Gender: males=629, females=983.</p>
<p>Triage: Included those who were deemed “non-urgent” by health professional.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To explore reasons for attending ED with less urgent health problems using Andersen’s Model of Health Services Use</p>
<p> </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>16 total items; only 7 reported on by authors (no % provided)</p>
<p>• Severity of symptoms (e.g., not willing to wait to see GP for pain)</p>
<p>• Concern it will get worse</p>
<p>• No other option</p>
<p>• No availability of GP</p>
<p>• Convenience of service</p>
<p>• Needed service only available at ED</p>
<p>• Tests only available at ED</p>
<p>• Advised to come from family/friends</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>31. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Hunt, DeHart et al. 1996)</p>
<p>USA</p>
<p>Cross-Sectional Survey</p>
<p>N=1547</p>
</td>
<td valign="top" width="20%">
<p>Mean age: Not Reported; Gender: Not Reported.</p>
<p>Triage: Patient severity was determined by the physician after they had been assessed and treated.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The purpose of this study was to examine patients' and physicians' perceptions of the urgency of need for emergency medical care, and why patients come to the ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Columbia Grand Strand Regional Medical Center (tourist community) – 6 most frequent reasons (N=557):</p>
<p>• I’m from out of town and just looked for the nearest emergency room. (23.0%)</p>
<p>• Don’t have a doctor/clinic that regularly takes care of me. (21.7%)</p>
<p>• Don’t have to make an appointment at the emergency room. (20.1%)</p>
<p>• Better medical care here than other places. (15.7%)</p>
<p>• My problem is bigger than my regular doctor/clinic could take care of. (14.6%)</p>
<p>• My doctor/clinic told me to come to the emergency department when the office is closed. (12.0%)<br> <br> </p>
<p>Pitt County Memorial Hospital (training program) – 6 most frequency reasons (N=990):</p>
<p>• Don’t have a doctor/clinic that regularly takes care of me. (15.6%)</p>
<p>• Better medical care than places. (14.3%)</p>
<p>• Don’t have to make an appointment at the emergency room. (12.7%)</p>
<p>• My doctor/clinic told me to come to the emergency department when the office is closed. (11.0%)</p>
<p>• My doctor couldn’t see me soon enough. (7.6%)</p>
<p>• My problem is bigger than my regular/clinic could take care of. (7.1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>32. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Idil, Kilic et al. 2018)</p>
<p>Turkey</p>
<p>Cross-sectional survey</p>
<p>N=624</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 38.4±14.4 yr; Gender: males=326, females=298.</p>
<p>Triage: Triage system with three levels (i.e., green, yellow, red); included patients were those with level green (i.e., lowest urgency, non-urgent patients that do not require urgent interventions and could be treated outside the ED in polyclinics or by their family physicians).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To explore reasons and factors influencing ED preference by non-urgent patients.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Able to get examined more quickly (36.4%)</p>
<p>• Not being able to book early appointments with alternative health units (30.9%)</p>
<p>• No given reason for preference to the ED (20.2%)</p>
<p>• ED is physically closer than the family physician (12.8%)</p>
<p>• Visited ED for complaints when they were at hospital for a different reason (12.3%)</p>
<p>• Other reasons (get medications prescribed, get incapacity report, or seek medical counselling services, etc.) (8.0%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>33. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Jalili, Shirani et al. 2013)</p>
<p>Iran</p>
<p>Cross-sectional survey administered via structured interview</p>
<p>N=1923 (non-urgent=400)</p>
</td>
<td valign="top" width="20%">
<p>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).</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with level 5 (non-urgent).</p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To estimate the number of ED visits that were due to nonurgent problems and to describe the</p>
<p>characteristics of those patients. </p>
<p> </p>
<p>To determine the reasons for nonurgent use of our ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Obtaining rapid care (77%)</p>
<p>• Proximity (52.8%)</p>
<p>• Low cost (20.8%)</p>
<p>• Unavailability of clinic area (19.8%)</p>
<p>• Better care (11.3%)</p>
<p>• Perception of urgent problems/urgency of the problem (10.8%)</p>
<p>• Having medical records in this hospital (10.3%)</p>
<p>• Being referred by a clinic or office (7.3%)</p>
<p>• Being an employee of this hospital (7.3%)</p>
<p>• Dissatisfaction with clinic or office (4.5%)</p>
<p>• Being brought by EMS ambulance (0.5%)</p>
<p>• No reasons mentioned (0.5%)</p>
<p>• Miscellaneous (0.5%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>34. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Jiang, Ye et al. 2020)</p>
<p>China</p>
<p>Cross-sectional survey</p>
<p>N=545</p>
</td>
<td valign="top" width="20%">
<p>Age: >18=152, 19-44=217, 45-64=123, >65=53; Gender: males=271, females=274.</p>
<p>Triage: Adaptation of 4-level (immediate, emergent, urgent, non-urgent) US Emergency Severity Index (ESI) triage; included all level 5 tests (i.e., mild complaints or discomforts).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The goal of this study was to explore the reasons for non-urgent ED presentations and identify individual characteristics that influence patients’ ED use patterns in mainland China.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• <em>Perceived severity of illness and urgent treatment needed (</em>68.6%) – illness is severe, advised by family/friends, need reassurance for their condition</p>
<p>• <em>Poor access of alternative services</em> (26.4%) – can’t get appointments, can’t get specific services elsewhere, alternatives not opened at this hour</p>
<p>• Referral by medical staff (24.6%)</p>
<p>• <em>Convenience and advantages of ED services</em> (21.5%) – easier to get appointment, evaluated/treated quickly, quality of care is superior, staff qualifications</p>
<p>• Unsure where else to go (4.6%)</p>
<p>• Regard ED as a regular medical resource (4.4%)</p>
<p>• Other reasons (0.4%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>35. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Laffoy, O'Herlihy et al. 1997)<br> Ireland</p>
<p>Cross-Sectional: Structured interview questionnaires</p>
<p>N=557</p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="20%">
<p>Age: 0-15 yr=10, 15-44 yr=367, 45-74 yr=128, 75+=30; Gender: not reported..</p>
<p>Triage: Included all self-referred and GP referred patients.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The aim of this study was to provide a profile of all</p>
<p>new patients who attended an AED of a south</p>
<p>city Dublin hospital; to document their reasons for</p>
<p>attending, the severity of the presenting condition, the</p>
<p>proportion who were self-referred or referred by a GP (GP) and to make comparisons between these two groups.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Thought I needed immediate attention (35.4%)</p>
<p>• Thought I needed an X-ray (18.2%)</p>
<p>• Hospital is convenient (13.7%)</p>
<p>• Thought GP would refer me anyway (7.6%)</p>
<p>• I prefer hospital for this condition (7.1%)</p>
<p>• I’m under hospital care already (5.6%)</p>
<p>• Hospital cheaper than GP (0.8%)</p>
<p>• GP told me to go to ED (0.3%)</p>
<p>• Other (14.4%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>36. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Lee, Lau et al. 2000)</p>
<p>Hong Kong</p>
<p>Telephone interviews,</p>
<p>using questionnaires</p>
<p>N=1374</p>
</td>
<td valign="top" width="20%">
<p>Age: 0-19 yr=561, 20-64 yr=728, 65+=85; Gender: males=735, females=639.</p>
<p>Triage: 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)</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To report the factors associated with inappropriate</p>
<p>utilization of accident and emergency services in Hong Kong.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Could not afford GP (61.2%)</p>
<p>• Proximity (21.2%)</p>
<p>• Better quality service at ED (13.4%)</p>
<p>• Efficient diagnosis (2.9%)</p>
<p>• Symptoms getting worse (0.1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>37. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Lobachova, Brown et al. 2014)</p>
<p>USA</p>
<p>Cross-Sectional Survey</p>
<p>N=1062</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 43.0±22.0 yr; Gender: males=552, females=510.</p>
<p>Triage: Not reported; all patients eligible for inclusion.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate reasons why patients choose ED for care and why primary care providers think patients utilize ED. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• I believed that my problem was serious (61%)</p>
<p>• My care provider told me to come (35%)</p>
<p>• I thought it was an emergency (26%)</p>
<p>• My illness occurred after hours (21%)</p>
<p>• It was suggested by family/friend (13%)</p>
<p>• I have no primary care provider (8%)</p>
<p>• I thought it was unnecessary to contact my regular provider (8%)</p>
<p>• The ED is convenient (8%)</p>
<p>• My primary care provider is not from here (7%)</p>
<p>• I could not get an appointment with MD (6%)</p>
<p>• I spoke to a specialist (5%)</p>
<p>• I did not know where else to go (3%)</p>
<p>• I don’t know (0.5%)</p>
<p>• I have no insurance (1%)</p>
<p>• Other (16%)</p>
<p>• Unspecified (16%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>38. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Marco, Weiner et al. 2012)</p>
<p>USA </p>
<p>Cross-Sectional Structured Survey via Interview</p>
<p>N=292</p>
</td>
<td valign="top" width="20%">
<p>Age: 18-39 yr=140, 40-64 yr=100, 65+=49; Gender: males=136, females=156.</p>
<p>Triage: No reported; all patients were eligible for inclusion.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To identify factors influencing patients' decisions to seek ED care and to assess primary care access. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Convenience/location (41%)</p>
<p>• No GP (37%)</p>
<p>• Institutional preference (23%)</p>
<p>• Emergency medical condition (19%)</p>
<p>• Issues with primary care (e.g., lack of available appointments, couldn’t get through, long wait, no on-call) (17%)</p>
<p>• Physician referral (14%)</p>
<p>• Primary care institutional affiliation (12%)</p>
<p>• Don’t know, didn’t think about it, no reason (6%)</p>
<p>• Other (7%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>39. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Masso, Bezzina et al. 2007)</p>
<p>Australia</p>
<p>Cross-Sectional Survey</p>
<p>N=397</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 38 yr (0-96 yr); Gender: males=222, females=175.</p>
<p>Triage: Australasian Triage Scale; included patients at levels 4 or 5 (i.e., presenting for a new episode of care, who did not</p>
<p>arrive by ambulance, were self-referred and who were</p>
<p>not expected to be admitted)</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To compare reasons identified by clinical staff for potential primary care attendances to the ED with those previously identified by patients.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• My health problem required immediate attention (67.3%)</p>
<p>• I am able to see the doctor and have any tests or X-rays all done at the same place (51.3%)</p>
<p>• My health problem was too serious or complex to see a GP (38.2%)</p>
<p>• I feel the medical treatment is better at the ED (15.4%)</p>
<p>• I am not happy with the time I have to wait to get to an appointment with a GP (12.6%)</p>
<p>• It is easier for me to go to the ED” (8.4%)</p>
<p>• I am not able to get in as a patient at GP surgery as the books are closed (7.6%)</p>
<p>• I wanted a second opinion (5.7%)</p>
<p>• I do not like making appointments (4.2%)</p>
<p>• I usually prefer to talk a doctor a don’t know about my health problems (3.4%)</p>
<p>• I did not want my GP to know about this health problem (1.6%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>40. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(McGuigan and Watson 2010)</p>
<p>UK </p>
<p>Cross-Sectional: Semi-structured telephone interviews</p>
<p>N=196</p>
</td>
<td valign="top" width="20%">
<p>Age: Not reported; Gender: Not reported.</p>
<p>Triage: Not reported; “Non-urgent, self-referred” attenders, not defined.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To discover factors influencing patients’ reason for attending the ED for non-urgent treatment. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Perceived appropriateness of condition (48%)</p>
<p>• After taking advice from others (mostly family) (35%)</p>
<p>• Anticipation of referral by GP (3%)</p>
<p>• Accessibility of ED (6%)</p>
<p>• Unavailability of GP (5%)</p>
<p>• Other (1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>41. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Miyazawa, Maeno et al. 2019)</p>
<p>Japan</p>
<p>Cross-sectional survey</p>
<p>N=231 </p>
<p>(Reported on Non-urgent ED subset=84)</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 43.5±18.5 yr; Gender: males=51, females=33.</p>
<p>Triage: Japan Triage and Acuity Scale (JTAS); included patients with level 4 (“less urgent”) or 5 (“non-urgent”).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The purpose of our study was to identify factors related to inappropriate ED use by comparing patients who sought medical care during regular consultation hours with those who visited EDs for out-of-hours care.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Inappropriate use group (N=84)</p>
<p>• Desired to be cured quickly (92.5%)</p>
<p>• Wanted a doctor’s opinion (90.6%)</p>
<p>• Wanted to know whether the condition was serious (83.9%)</p>
<p>• Condition was not improving (80.6%)</p>
<p>• Wanted a prescription (76.7%)</p>
<p>• Wanted a laboratory test done (65.1%)</p>
<p>• Desire for treatment by a specialist (59.3%)</p>
<p>• Recommended by others (45.8%)</p>
<p>• Over-the-counter medicine was not working (35.6%)</p>
<p>• Wanted to know if they could attend work, school, events (24.1%)</p>
<p>• Wanted an intravenous drip (20.7%)</p>
<p>• Inability to take time off from school or work during the day (38.7% of inappropriate group)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>42. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Moll van Charante, ter Riet et al. 2008)</p>
<p>Netherlands</p>
<p>Postal questionnaires</p>
<p>N=224</p>
</td>
<td valign="top" width="20%">
<p>Median age: 33 yr (IQR 30); Gender: males=175, females=49.</p>
<p>Triage: Not reported; included all patients who had self-referred to ED.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine self-referrals’ motives to visit ED and to compare their characteristics to patients contacting the GP cooperative </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Additional investigations were necessary (36%)</p>
<p>• ED physician is best qualified for the problem (30%)</p>
<p>• ED is more accessible than the GP (16%)</p>
<p>• Related to a recent hospital contact or procedure (5%)</p>
<p>• Did not want to disturb the GP or no GP available (4%)</p>
<p>• Other (5%)</p>
<p>• No response (4%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>43. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Müller, Winterhalder et al. 2012)</p>
<p>Switzerland</p>
<p>Cross-Sectional Survey</p>
<p>N=200</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 35.5 yr (15-83 yr); Gender: males=129, females=71.</p>
<p>Triage: Not reported; all patients were eligible for inclusion.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate why walk-in patients use ED during GP office hours. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Didn’t want to disturb GP (2.5%)</p>
<p>• ED can help better (14.0%)</p>
<p>• ED has better infrastructure (14%)</p>
<p>• GP is too far away (9%)</p>
<p>• I couldn’t reach the GP (15%)</p>
<p>• I have no GP (10.5%)</p>
<p>• Low confidence in GP (2.5%)</p>
<p>• Other (12%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>44. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Nelson 2011)</p>
<p>Scotland UK </p>
<p>Telephone interviews using structured questionnaire</p>
<p>N=27</p>
</td>
<td valign="top" width="20%">
<p>Age: 16-40 yr=20, 40+=7;</p>
<p>Gender: males=13, females=14.</p>
<p>Triage: Included patients whose conditions were determined to be “standard and non-urgent”</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To understand patients’ perceptions of the urgency of their condition and how this influences their decision to attend EDs </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Need for x-rays (37%)</p>
<p>• Referred by their GP (15%)</p>
<p>• Advised by the health centre receptionist to attend the ED (7%)</p>
<p>• Unable to obtain a GP appointment (4%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>45. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Norredam, Mygind et al. 2007)</p>
<p>Denmark</p>
<p>Cross-sectional survey</p>
<p>N=3426</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 0-14 yr=617, 15-24 yr=624, 25-44 yr=1343, 45+=781; Gender: males=1925, females=1501.</p>
<p>Triage: Not reported; all patients were eligible for inclusion.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate if patients who are immigrants or Danish origin have different reasons for seeking ED care. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• The ED is most relevant to my need (63%)</p>
<p>• I was referred by a primary caregiver (24%)</p>
<p>• I could not get in contact with a GP (13%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>46. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Northington, Brice et al. 2005)</p>
<p>USA</p>
<p>Cross-sectional survey</p>
<p>N=279</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 37.4±14.9 yr; Gender: males=154, females=125.</p>
<p>Triage: Emergency Severity Index (ESI): Patients included had ESI levels 4 or 5 indicating non-urgent (i.e., responsive, oriented, in no acute distress, have stable vital signs, require <2 resources)</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The objectives of this study are (1) to determine whether patients seeking ED non-urgent care have primary care providers or know of other care sources and</p>
<p>(2) to determine the reasons why they choose to use the ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Better care (76.1%)</p>
<p>• Urgency (73.6%)</p>
<p>• Immediacy (68.6%)</p>
<p>• Payment flexibility (41.9%)</p>
<p>• Expediency (39.7%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>47. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Oetjen, Oetjen et al. 2010)</p>
<p>USA</p>
<p>Cross-Sectional: Survey questionnaire</p>
<p>N=438</p>
</td>
<td valign="top" width="20%">
<p>Age: 2-18 yr=127, 19-50 yr=197, 50-80 yr=114; Gender: males=29%, females=70%. </p>
<p>Triage: Only non-urgent included defined as “those cases in which the patient does not require immediate care or attention within a few hours.”</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To understand why insured patients use EDs rather than more appropriate medical alternatives available. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Patient believed condition was serious (72%)</p>
<p>• Primary care physician referred them (57%)</p>
<p>• After-hours (9%)</p>
<p>• Insurance (8%)</p>
<p>• ED was more convenient: quality (10%)</p>
<p>• ED was more convenient: location (14%)</p>
<p>• ED was more convenient: staff (51%)</p>
<p>• Friends recommended coming (9%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>48. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Oktay, Cete et al. 2003)</p>
<p>Turkey</p>
<p>Cross-sectional survey</p>
<p>N=1155</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 44.9±18.1 yr; Gender: males=503, females=652.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with CTAS 3-5 (urgent, less-urgent, non-urgent, respectively).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine the patterns and appropriateness of patients’ use of a university hospital ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Proximity to ED (19.8%)</p>
<p>• Satisfaction with care (12.5%)</p>
<p>• Pain and worsening of symptoms (11.5%)</p>
<p>• Clinic care unavailable (11.3%)</p>
<p>• Quick care and laboratory results (8.5%)</p>
<p>• Always get care in this hospital (7.6%)</p>
<p>• Perception of serious illness (6.4%)</p>
<p>• Told to go to ED by relatives or others (4.7%)</p>
<p>• Trust out ED care (2.8%)</p>
<p>• Thought symptoms would become intensified (2.6%)</p>
<p>• Told to come to our ED for follow up (2.4%)</p>
<p>• Relatives work in our ED (2.1%)</p>
<p>• Miscellaneous (7.8%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>49. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(O’Loughlin M 2019)</p>
<p>Australia</p>
<p>Cross-sectional survey</p>
<p>N=1000</p>
<p> </p>
<p> </p>
<p> </p>
<p> </p>
</td>
<td valign="top" width="20%">
<p>Mean age: 48.6±19.0 yr; Gender: males=493, females=507.</p>
<p>Triage: Not reported; included patients with “potentially avoidable general practitioner (PAGP)-type presentations.”</p>
<p> </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To explore the patient perspective of health services in a regional centre, with a focus on people living with chronic conditions […] to explore people who attend the ED in terms of their rationale for presentation […] to determine their knowledge and experience of local healthcare services; and to identify opportunities for alternate, appropriate patient-centred care.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• No choice/urgent problem (35.5%)</p>
<p>• Best place for problem (25.0%)</p>
<p>• Services in one location (11.6%)</p>
<p>• Open 24 hours (4.6%)</p>
<p>• Quicker than a general practice (3.2%)</p>
<p>• Need admission (2.6%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>50. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Penson, Coleman et al. 2012)</p>
<p>UK</p>
<p>Observational: Survey</p>
<p>N=261</p>
</td>
<td valign="top" width="20%">
<p>Age: 14-34 yr=108, 35-55 yr=77, 55+ yr=77; Gender: males=140, females=121.</p>
<p>Triage: “Minor” injury unit based on a list of explicit criteria.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To estimate the potential for patients with minor or moderate conditions to be managed in settings other than the ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Ranges reflect the sub-themes of reasons within each overall category endorsed by patients:</p>
<p>• Availability of other services (i.e., no GP or no availability) (6-69%)</p>
<p>• Awareness of other services (i.e., not sure where to go, unsure of other services, when open) (16-46%)</p>
<p>• Patient preferences (i.e., not wanting to see their GP, can’t always see the same one, not wanting to bother them) (6-15%)</p>
<p>• Positive experiences of ED (i.e., confident, happy) (60-74%)</p>
<p>• Processes and patient’s time (i.e., GP would refer to ED anyway, seen quicker, do not have to wait for appointment) (17-48%)</p>
<p>• Convenience of access (i.e., location, ease) (18-29%)</p>
<p>• Perceptions of seriousness (21-98%)</p>
<p>• Reassurance (91%)</p>
<p>• Second opinion (25%)</p>
<p>• Directed by others (36-78%)</p>
<p>• Seeking particular services (4-84%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>51. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Porro, Monzani et al. 2013)</p>
<p>Italy</p>
<p>Cross-sectional survey administered via structured interview</p>
<p>N=583</p>
</td>
<td valign="top" width="20%">
<p>Age: Not reported; Gender: Not reported.</p>
<p>Triage: 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).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate the inappropriate access to the Emergency Room of a major metropolitan teaching hospital.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Possibility to obtain all necessary examination at the same time (N=232)</p>
<p>• Fastest solution for complaint (N=187)</p>
<p>• Closest solution (N=169)</p>
<p>• Suggested by a pharmacist (N=99)</p>
<p>• Could not wait for family doctor visiting hours (N=97)</p>
<p>• Suggested by relatives/friends (N=60)</p>
<p>• Cheapest solution (N=12)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>52. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Ragin, Hwang et al. 2005)</p>
<p>USA</p>
<p>Questionnaires and interviews</p>
<p>N=1536</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 45.9±19.3 yr; Gender: males=685, females=851.</p>
<p>Triage: Not reported: all patients were eligible for inclusion.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To identify the principal reasons why patients seek care in hospital EDs in the United States.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Medical necessity – perceived ED was the place to be (95.0%)</p>
<p>• Convenience (86.5%)</p>
<p>• Preference of ED over alternate services (88.7%)</p>
<p>• Affordability (25.2%)</p>
<p>• Limitations of insurance (14.9%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>53. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Rajpar, Smith et al. 2000)<br> UK</p>
<p>Semi-structured questionnaire completed via interviews</p>
<p>N=102 (N=54 ED only)</p>
</td>
<td valign="top" width="20%">
<p><em>ED Patients: </em>Mean age: 27.9 yr; Gender: males=26, females=28.</p>
<p>Triage: Patients with primary care problems 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).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine the reasons for</p>
<p>choosing between primary care out of hours centres and AED for patients with primary care problems.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Stated “GP was closed” (50.0%)</p>
<p>• Perceived severity of problem (22.2%)</p>
<p>• Did not want to disturb their GP (11.1%)</p>
<p>• Wanted second opinion (7.4%)</p>
<p>• Perceived wait time in ED shorter than at GP (5.6%)</p>
<p>• Perceived that facility and investigations better at ED (3.7%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>54. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Rassin, Nasie et al. 2006)</p>
<p>Israel</p>
<p>Cross-sectional survey</p>
<p>N=73</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 39.4 yr (18-82 yr); Gender: males=44, females=29.</p>
<p>Triage: Not reported; all patients eligible for inclusion.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>The aim of the study was to identify the characteristics of self-referrals for non-urgent conditions to the emergency room, and compare urgency evaluation between patients and nurses.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Recommendation of a family member (68.6%)</p>
<p>• Quality of ED greater than primary care (62.9%)</p>
<p>• Geographical proximity to their home (47.2%)</p>
<p>• Usually when they feel sick they go to the ED (43%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>55. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Redstone, Vancura et al. 2008)</p>
<p>USA</p>
<p>Cross-sectional survey</p>
<p>N=240</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 45yr; Gender: males=76, females=164.</p>
<p>Triage: Emergency Severity Index (ESI); all patients with ESI levels 3-5 (non-urgent).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate why patients with minor problems and a primary care physician present to ED and to assess if this differs between weekday and non-weekday times. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Could not wait 1-2 days (93%)</p>
<p>• ED more convenient (62%)</p>
<p>• Need a test not available at GP (51%)</p>
<p>• Problem too complex for GP (45%)</p>
<p>• Advised to go to ED (49%)</p>
<p>• Perceived need of hospital admittance (24%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>56. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Rieffe, Oosterveld et al. 1999)</p>
<p>Netherlands</p>
<p>Cross-sectional questionnaire</p>
<p>N=430</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 31.0±15.1 yr; Gender: males=280, females=150.</p>
<p>Triage: Patients were included if their condition lasted >24 hr, and according to a classification scheme created by ED experts and applied by a medical student.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate the reasons why patients visit the ED and to determine the influence of patient characteristics on specific motives.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• 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. </p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>57. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Schumacher, Hall et al. 2013)</p>
<p>USA</p>
<p>Structured interviews based on a survey</p>
<p>N=492</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 41±17 yr; Gender: males=221, females=271.</p>
<p>Triage: Emergency Severity Index (ESI); patients were included of any ESI level but categorized into high acuity (ESI 1-2) and less urgent (ESI 3-35).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To examine the relationship between health literacy, access to primary care and reasons for ED use among adults presenting for emergency care. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Right place to go (92%)</p>
<p>• Emergency (89%)</p>
<p>• Worried (93%)</p>
<p>• Too much pain (73%)</p>
<p>• Too sick or injured (52%)</p>
<p>• Do not like usual (13%)</p>
<p>• Medical records are at ED (41%)</p>
<p>• Better care at the ED (61%)</p>
<p>• Always get care in ED (47%)</p>
<p>• Like environment of the ED (25%)</p>
<p>• No insurance (21%)</p>
<p>• Financial (22%)</p>
<p>• MD-refused insurance (3%)</p>
<p>• One stop (63%)</p>
<p>• No appointment necessary (45%)</p>
<p>• Closest or easiest place (54%)</p>
<p>• No place to go (55%)</p>
<p>• Only place open (26%)</p>
<p>• Language (33%)</p>
<p>• Family or friends (32%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>58. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Selasawati, Naing et al. 2007)</p>
<p>Maylasia</p>
<p>Cross-sectional survey</p>
<p>N=170 (case)</p>
<p>N=170 (control)</p>
</td>
<td valign="top" width="20%">
<p><em>Case (ED Patients; N=170)</em>: Mean age: 36.7±13.6 yr; Gender: males=97, females=73. </p>
<p><em>Control (Outpatients; N=170)</em>: Mean age: 40.2±14.6 yr; Gender: males=46, females=124.</p>
<p>Triage: Based on 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.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine the associated factors and the reasons for inappropriate utilisation of ED services.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Due to severity of illness (85%)</p>
<p>• Can’t go to OPD during office hours (42%)</p>
<p>• ED near house (27%)</p>
<p>• Better treatment in ED (26%)</p>
<p>• Staff or family member (17%)</p>
<p>• No other place to go (15%)</p>
<p>• Financial problem (8.8%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>59. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Shah, Shah et al. 1996)</p>
<p>Kuwait</p>
<p>Cross-Sectional Survey</p>
<p>N=1986 </p>
<p>(N=1212 non-urgent, self-referred only)</p>
</td>
<td valign="top" width="20%">
<p>(Non-urgent, self-referred only; N=1212): Age: <25 yr=266, 25-34 yr=392, 35-49 yr=349, 50+=205; </p>
<p>Gender: males=691, females=521.</p>
<p>Triage: 4-level triage system from emergency (level 1) to non-urgent (level 4); only included level 4 non-urgent patients who self-referred to ED. </p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To analyze the factors that act as predictors of non-urgent visits by nationals as well as expatriates. </p>
</td>
<td valign="top" width="36.89655172413793%">
<p><em>Preference</em></p>
<p>• ED better or clinic worse/medicine not available (27.8%)</p>
<p><em>Accessibility/availability</em></p>
<p>• Accessibility/availability of ED (59.8%)</p>
<p>• Hospital staff (14.0%)</p>
<p>• Clinic closed/not available/do not know clinic schedule (7.5%)</p>
<p>• ED close by or convenient (13.2%)</p>
<p>• Regular patient (12.1%)</p>
<p>• Refused by primary care physician (2.0%)</p>
<p><em>Perceived Urgency</em></p>
<p>• Perceived condition to be urgent (10.7%)</p>
<p><em>Other (1.6%)</em></p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>60.</p>
<p> </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Siminski, Cragg et al. 2005)</p>
<p>Australia</p>
<p>Cross-sectional Survey</p>
<p>N=400</p>
</td>
<td valign="top" width="20%">
<p>Mean age: not reported; Gender: not reported.</p>
<p>Triage: Australian Triage Scale; included patients with levels 4 or 5 only (i.e., non-urgent).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate why some patients with apparently less urgent conditions present to EDs.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Problem too urgent (80%)</p>
<p>• See doctor and testing done in same place (74%)</p>
<p>• Problem too serious/complex (53%)</p>
<p>• Medical treatment better at ED (34%)</p>
<p>• Not happy with GP waiting time (24%)</p>
<p>• Easier to get to the ED (21%)</p>
<p>• Not able to see GP as books are closed (16%)</p>
<p>• Second opinion (14%)</p>
<p>• Do not like making appointments (12%)</p>
<p>• No charge for X-rays or medicine (10%)</p>
<p>• No charge to see a doctor (9%)</p>
<p>• Traditional use by family (9%)</p>
<p>• Prefer doctor I don’t know (6%)</p>
<p>• Prefer ED environment (5%)</p>
<p>• Did not want the GP to know (2%)</p>
<p>• Female doctor (2%)</p>
<p>• Doctor/interpreter with native language (2%)</p>
<p>• Aboriginal health staff (2%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>61. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Steele, Anstett et al. 2008)</p>
<p>Canada</p>
<p>Cross-sectional survey</p>
<p>N=137</p>
</td>
<td valign="top" width="20%">
<p>Mean age: not specified; Gender: not specified.</p>
<p>Triage: Canadian Triage and Acuity Scale (CTAS); included patients with levels 4 and 5 only (i.e., less-urgent and non-urgent, respectively).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine if the reasons for less- or non-urgent ED use applied to patients presenting with problems triaged at a similar level at a low-volume rural ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Needed treatment as soon as possible (38.7%)</p>
<p>• Needed a specific service offered in the ED (32.8%)</p>
<p>• Walk-in clinic was closed (24.8%)</p>
<p>• Family physician’s office was closed (21.9%)</p>
<p>• Could not wait for appointment with family physician (16.8%)</p>
<p>• Did not have a family physician (4.4%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>62. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Thomson, Kohli et al. 1995)</p>
<p>UK</p>
<p>Cross-Sectional Survey</p>
<p>N=245</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 28.5 yr; Gender: males=162, females=83.</p>
<p>Triage: Included non-emergent patients (i.e., did not require immediate attention by a physician and could wait as necessary) and who had attended the ED without previously contacted their GP.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate factors related to the bypassing of GPs by 'self-referred' patients and inappropriate</p>
<p>use of the ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Easier geographical access (15%)</p>
<p>• Convenience-related to timing (24%)</p>
<p>• GPs perceived inability to treat disorder (59%)</p>
<p>• Other (3%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>63. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Thornton, Fogarty et al. 2014)<br> New Zealand</p>
<p>Cross-sectional survey</p>
<p>N=421</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 37.6±24.6 yr; Gender: males=203, females=218.</p>
<p>Triage: Australasian Triage Scale; included only patients with levels 3-5 who self-referred to ED.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To identify reasons for attend an ED rather a GP for self-referrals to ED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Among those who contacted their GP (25%), they were advised to go to ED (73%)</p>
<p>• GP was closed (29%)</p>
<p>• Felt sick enough to require ED care (32%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>64. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Unwin, Kinsman et al. 2016)</p>
<p>Australia</p>
<p>Cross-sectional survey</p>
<p>N=477</p>
</td>
<td valign="top" width="20%">
<p>Age: <25 yr=217, >25 yr=260; Gender: males=224, females=253.</p>
<p>Triage: Australian Triage Score (ATS); included patients with levels 4 and 5 only (i.e., non-urgent).</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To identify profiles in non-urgent presentations and gain insight into: services accessed before presentation to ED; why ED was chosen by attendees with non-urgent complaints and the presenting health complaint of attendees.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• It was clearly an emergency to me (37.1%)</p>
<p>• Patient may need to have tests (such as x-rays and/or blood tests) (40.3%)</p>
<p>• ED more available than GP or other health care service (28.7%)</p>
<p>• GP not available (35.8%)</p>
<p>• Patient was told to go to ED by a doctor or nurse (28.9%)</p>
<p>• A health help line indicated the patient should attend (5.0%)</p>
<p>• It was related to a recent hospital contact or procedure (5.7%)</p>
<p>• Other services are too expensive (6.9%)</p>
<p>• The patient uses the ED for all their health concerns (2.1%)</p>
<p>• Did not know where else to go (9.2%)</p>
<p>• Other (6.9%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>65. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Walsh 1995)<br> UK</p>
<p>Qualitative and Quantitative: Structured interviews</p>
<p>N=200</p>
</td>
<td valign="top" width="20%">
<p>Age range: 16-60 yr;</p>
<p>Gender: males=100, females=100.</p>
<p>Triage: Individuals who presented to the “minor injury” section of an ED; otherwise, unspecified.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To examine the reasons why people attend AED and the</p>
<p>factors that delay or accelerate attendance, utilizing a framework espoused in</p>
<p>the medical sociology literature (Health Belief Model).</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• ED more appropriate or better than GP (20%)</p>
<p>• GP would send me here anyway (17%)</p>
<p>• Quicker/wait too long for GP appointment (17%)</p>
<p>• Sent by GP after initially going to GP (14.5%)</p>
<p>• Advised to go to ED by others than GP (13.5%)</p>
<p>• More convenient than GP (11.5%)</p>
<p>• GP not available (10.5%)</p>
<p>• No GP or GP >25 miles away (9%)</p>
<p>• Other (2%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>66. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Wang, Tchopev et al. 2015)</p>
<p>USA</p>
<p>Cross-sectional survey</p>
<p>N=2711</p>
</td>
<td valign="top" width="20%">
<p>Female mean age (N=1746): 26.7±17.5 yr; Male mean age (N=965): 19.9±19.6 yr.</p>
<p>Triage: Not reported; included patients Medicaid members attending ED.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To investigate patient-reported reasons for treat-and-release ED visits by Medicaid</p>
<p>beneficiaries.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p><em>Health care service delivery issues:</em></p>
<p>• Access (11.0%)</p>
<p>• Primary care provider unavailable (44.9%)</p>
<p><em>Population behaviour issues</em></p>
<p>• Dissatisfaction with primary care provider (0.6%)</p>
<p>• Medication needs (0.2%)</p>
<p>• Unaware of primary care provider (0.8%)</p>
<p>• Usual place of care (0.3%)</p>
<p><em>Unavoidable ED visits</em></p>
<p>• Acute conditions (38.2%)</p>
<p>• Referral by primary care provider (4.1%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>67. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Ward, Huddy et al. 1996)</p>
<p>UK</p>
<p>Cross-sectional survey (single question)</p>
<p>N=970</p>
</td>
<td valign="top" width="20%">
<p>Age range: 21-30 yr (344/965 patients with complete data); Gender: not reported. Triage: Minor B/primary care=100%.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To determine the characteristics of primary care attenders to St. Mary’s Hospital AED.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Question answered by 339 patients:</p>
<p>• Problem not appropriate for GP (27.1%)</p>
<p>• Not convenient to see GP (22.4%)</p>
<p>• Advised by health professional 39 (11.5%)</p>
<p>• Second opinion (9.7%)</p>
<p>• Did not try to see GP (9.7%)</p>
<p>• Appointment not available with GP (7.4%)</p>
<p>• Unable to contact GP (6.2%)</p>
<p>• Dissatisfied with GP (4.4%)</p>
<p>• Other (1.5%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>68. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Watson, Ferguson et al. 2015)</p>
<p>UK</p>
<p>Cross-sectional survey</p>
<p>N=81</p>
</td>
<td valign="top" width="20%">
<p>Mean age: 42.2±17.9 yr; Gender: males=36, females=43; missing=2.</p>
<p>Triage: Included patients who requested treatment for a minor ailment or symptoms of a minor ailment (i.e., “common or self-limiting or uncomplicated conditions which may be diagnosed and managed without medical intervention.”</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To compare outcomes of consultations suggestive of minor ailments in EDs, GPs and pharmacies.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>Major categories (range reported by subcategories of reasons)</p>
<p>• Convenient location (1.2%-51.9%)</p>
<p>• Knowing, feeling comfortable, or trusting the staff (1.2%-34.6%)</p>
<p>• Condition too serious to go to GP or chemist (27.2%-30.9%)</p>
<p>• Previously attended GP or chemist but condition not improved (3.7%-16.0%)</p>
<p>• Have to wait longer for a GP appointment (37.0%)</p>
<p>• Prefer not to go to GP or chemist (3.7%-4.9%)</p>
<p>• Cost of treatment (1.2%)</p>
</td>
</tr>
<tr>
<td style="width: 7.6087%;" valign="top" width="8.045977011494253%">
<p>69. </p>
</td>
<td style="width: 22.6812%;" valign="top" width="16.20689655172414%">
<p>(Young, Wagner et al. 1996)</p>
<p>USA</p>
<p>Cross-sectional survey</p>
<p>N=6187</p>
</td>
<td valign="top" width="20%">
<p>Median age: 31 yr, <18 yr=24%; Gender: males=3046, females=3141.</p>
<p>Triage: Included patients were 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.</p>
</td>
<td valign="top" width="18.850574712643677%">
<p>To characterize the reasons ambulatory patients’ use hospital EDs for outpatient care and to determine the proportion of ED patients who initially are assessed as having nonurgent conditions, but subsequently are hospitalized.</p>
</td>
<td valign="top" width="36.89655172413793%">
<p>• Emergent or urgent condition (39%)</p>
<p>• Told to go to ED by clinician (19%)</p>
<p>• Too sick to go elsewhere (6%)</p>
<p>• Get good care in the ED (11%)</p>
<p>• Get diagnosis and/or treatment (11%)</p>
<p>• Barriers to receiving care elsewhere (65%)</p>
<p>• Clinic not open at night/not get off work (11%)</p>
<p>• Nowhere else to go for care (11%)</p>
<p>• Geographical reasons (8%)</p>
<p>• Tried to get care elsewhere (4%)</p>
<p>• Transportation problems (3%)</p>
<p>• Clinic does not take walk-in patients (3%)</p>
<p>• No money or insurance (8%)</p>
<p>• Free or low-cost ED care (4%)</p>
<p>• Insurance or work requirement (2%)</p>
<p>• Insurance pays for ED care (1%)</p>
</td>
</tr>
</thead>
Note: AED= Accident and Emergency Room; ED= Emergency Department; ER= Emergency Room; GP=General Practitioner
Table 4. Quality assessments of qualitative articles using a CASP checklist
Author, Year
|
CASP 1
|
CASP 2
|
CASP 3
|
CASP 4
|
CASP 5
|
CASP 6
|
CASP 7
|
CASP 8
|
CASP 9
|
CASP 10
|
|
Was there a clear statement of the aims of the research?
|
Is a qualitative methodology appropriate?
|
Was the research design appropriate to address the aims of the research?
|
Was the recruitment strategy appropriate to the aims of the research?
|
Was the data collected in a way that addressed the research issue?
|
Has the relationship between researcher and participants been adequately considered?
|
Have ethical issues been taken into consideration?
|
Was the data analysis sufficiently rigorous?
|
Is there a clear statement of findings?
|
How valuable is the research?
|
(Agarwal, Banerjee et al. 2012)
|
✔
|
✔
|
✔
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Benger and Jones 2008)
|
✔
|
✔
|
✔
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Bornais, Crawley et al. 2020)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Claver 2011)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Durand, Palazzolo et al. 2012)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Gomide MF 2012)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Goodridge and Stempien 2019)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Guttman, Zimmerman et al. 2003)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Henninger, Spencer et al. 2019)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Howard, Davis et al. 2005)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Keizer Beache and Guell 2016)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Koziol-McLain, Price et al. 2000)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Kraaijvanger, Rijpsma et al. 2017)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Long, Knowles et al. 2021)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Matifary, Wachira et al. 2021)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(McKenna, Rogers et al. 2020)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Palmer, Jones et al. 2005)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(Pförringer, Pflüger et al. 2021)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
X
|
✔
|
✔
|
(Read, Varughese et al. 2014)
|
✔
|
✔
|
✔
|
✔
|
✔
|
NR
|
NR
|
NR
|
✔
|
✔
|
(Shaw, Howard et al. 2013)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
(van der Linden, Lindeboom et al. 2014)
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
✔
|
Note. P Reported; NR = Not Reported
Table 5. Quality assessments of quantitative articles using an adapted NIH
Author, Year
|
NIH 1
|
NIH 2
|
NIH 3
|
NIH 4
|
NIH 5
|
NIH 11
|
NIH 14 - modified
|
Was the research question or objective clearly stated?
|
Was the study population clearly specified and defined?
|
Was the participation rate of eligible persons at least 50%?
|
Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
|
Was a sample size justification, power description, or variance and effect estimates provided?
|
Were the outcome measures (dependent variables) clearly defined, valid and reliable and implemented consistently across all study participants?
|
Were key potential confounding variables measured? (i.e., Was there a statement of findings?)
|
(Afilalo, Guttman et al. 1995)
|
✔
|
✔
|
56.0%
|
✔
|
NR
|
✔
|
✔
|
(Afilalo, Marinovich et al. 2004)
|
✔
|
✔
|
77.0%
|
✔
|
P
|
✔
|
✔
|
(Al-Otmy, Abduljabbar et al. 2020)
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Alyasin and Douglas 2014)
|
✔
|
✔
|
98.3%
|
✔
|
NR
|
✔
|
✔
|
(Amiel, Williams et al. 2014)
|
✔
|
✔
|
58.0%
|
✔
|
✔
|
✔
|
✔
|
(Atenstaedt, Gregory et al. 2015)
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Bahadori, Mousavi et al. 2019)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Baker, Stevens et al. 1995)
|
✔
|
✔
|
69.0%
|
✔
|
NR
|
✔
|
✔
|
(Barbadoro, Di Tondo et al. 2015)
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Baskin, Baker et al. 2015)
|
✔
|
NR
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Becker, Dell et al. 2012)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Bianco, Pileggi et al. 2003)
|
✔
|
✔
|
86.1%
|
✔
|
NR
|
✔
|
NR
|
(Brasseur, Gilbert et al. 2021)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Brim 2008)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Burchard, Oikonomoulas et al. 2019)
|
✔
|
✔
|
32.9%
|
✔
|
NR
|
✔
|
✔
|
(Coelho Rodrigues Dixe, Passadouro et al. 2018)
|
✔
|
✔
|
11.9%
|
✔
|
✔
|
✔
|
✔
|
(Cheek, Allen et al. 2016)
|
✔
|
✔
|
84.2%
|
✔
|
✔
|
✔
|
✔
|
(Coleman, Irons et al. 2001)
|
✔
|
✔
|
91.0%
|
✔
|
✔
|
✔
|
✔
|
(Dawoud, Ahmad et al. 2015)
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(de Valk, Taal et al. 2014)
|
✔
|
✔
|
47.0%
|
✔
|
NR
|
✔
|
✔
|
(Diserens, Egli et al. 2015)
|
✔
|
✔
|
68.7% (2013)
NR (2000)
|
✔
|
NR
|
✔
|
✔
|
(Faulkner and Law 2015)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Field and Lantz 2006)
|
✔
|
✔
|
67.0%
|
✔
|
NR
|
✔
|
✔
|
(Galanis, Siskou et al. 2019)
|
✔
|
NR
|
NR
|
NR
|
NR
|
NR
|
✔
|
(Gentile, Vignally et al. 2010)
|
✔
|
✔
|
77.2%
|
✔
|
NR
|
✔
|
✔
|
(Ghazali, Richard et al. 2019)
|
✔
|
✔
|
59.0% (site 1)
63.7% (site 2)
|
✔
|
✔
|
✔
|
✔
|
(Gill and Riley 1996)
|
✔
|
✔
|
95.0%
|
✔
|
NR
|
✔
|
✔
|
(Graham, Kwok et al. 2009)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Han, Ospina et al. 2007)
|
✔
|
✔
|
68.0%
|
✔
|
✔
|
✔
|
✔
|
(Hodgins and Wuest 2007)
|
✔
|
✔
|
90.0%
|
✔
|
✔
|
✔
|
✔
|
(Hunt, DeHart et al. 1996)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Idil, Kilic et al. 2018)
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Jalili, Shirani et al. 2013)
|
✔
|
✔
|
96.8%
|
✔
|
✔
|
✔
|
✔
|
(Jiang, Ye et al. 2020)
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Laffoy, O'Herlihy et al. 1997)
|
✔
|
✔
|
89.1%
|
NR
|
NR
|
✔
|
✔
|
(Lee, Lau et al. 2000)
|
✔
|
✔
|
57.0%
|
✔
|
✔
|
✔
|
✔
|
(Lobachova, Brown et al. 2014)
|
✔
|
✔
|
71.0%
|
✔
|
✔
|
✔
|
✔
|
(Marco, Weiner et al. 2012)
|
✔
|
✔
|
89.0%
|
✔
|
✔
|
✔
|
✔
|
(Masso, Bezzina et al. 2007)
|
✔
|
✔
|
99.3%
|
✔
|
✔
|
✔
|
✔
|
(McGuigan and Watson 2010)
|
✔
|
✔
|
81.6%
|
✔
|
NR
|
✔
|
✔
|
(Miyazawa, Maeno et al. 2019)
|
✔
|
✔
|
57.0%
|
✔
|
✔
|
✔
|
✔
|
(Moll van Charante, ter Riet et al. 2008)
|
✔
|
✔
|
66.0%
|
✔
|
NR
|
✔
|
✔
|
(Müller, Winterhalder et al. 2012)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Nelson 2011)
|
✔
|
✔
|
45.0%
|
✔
|
NR
|
✔
|
✔
|
(Norredam, Mygind et al. 2007)
|
✔
|
✔
|
54.0%
|
✔
|
NR
|
✔
|
✔
|
(Northington, Brice et al. 2005)
|
✔
|
✔
|
55.8%
|
✔
|
NR
|
✔
|
✔
|
(Oetjen, Oetjen et al. 2010)
|
✔
|
✔
|
99.4%
|
✔
|
NR
|
✔
|
✔
|
(Oktay, Cete et al. 2003)
|
✔
|
✔
|
96.2%
|
✔
|
NR
|
✔
|
✔
|
(O’Loughlin M 2019)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Penson, Coleman et al. 2012)
|
✔
|
✔
|
89.7%
|
✔
|
✔
|
✔
|
✔
|
(Porro, Monzani et al. 2013)
|
✔
|
✔
|
NR
|
CD
|
NR
|
✔
|
✔
|
(Ragin, Hwang et al. 2005)
|
✔
|
✔
|
78.5%
|
✔
|
NR
|
✔
|
✔
|
(Rajpar, Smith et al. 2000)
|
✔
|
✔
|
NR
|
NR
|
NR
|
✔
|
✔
|
(Rassin, Nasie et al. 2006)
|
✔
|
✔
|
91.3%
|
✔
|
NR
|
NR
|
✔
|
(Redstone, Vancura et al. 2008)
|
✔
|
✔
|
87.0%
|
✔
|
NR
|
✔
|
✔
|
(Rieffe, Oosterveld et al. 1999)
|
✔
|
✔
|
66.0%
|
✔
|
NR
|
NR
|
NR
|
(Schumacher, Hall et al. 2013)
|
✔
|
✔
|
95.0%
|
✔
|
✔
|
✔
|
✔
|
(Selasawati, Naing et al. 2007)
|
✔
|
✔
|
NR
|
✔
|
✔
|
✔
|
✔
|
(Shah, Shah et al. 1996)
|
✔
|
✔
|
92.8%
|
✔
|
NR
|
✔
|
✔
|
(Siminski, Cragg et al. 2005)
|
✔
|
✔
|
99.0%
|
✔
|
NR
|
✔
|
✔
|
(Steele, Anstett et al. 2008)
|
✔
|
✔
|
97.2%
|
✔
|
NR
|
✔
|
✔
|
(Thomson, Kohli et al. 1995)
|
✔
|
NR
|
90.7%
|
NR
|
NR
|
✔
|
✔
|
(Thornton, Fogarty et al. 2014)
|
✔
|
✔
|
84.2%
|
✔
|
NR
|
✔
|
✔
|
(Unwin, Kinsman et al. 2016)
|
✔
|
✔
|
16.0%
|
✔
|
NR
|
✔
|
✔
|
(Walsh 1995)
|
✔
|
✔
|
NR
|
✔
|
NR
|
✔
|
✔
|
(Wang, Tchopev et al. 2015)
|
✔
|
✔
|
13.4%
|
✔
|
NR
|
✔
|
✔
|
(Ward, Huddy et al. 1996)
|
✔
|
✔
|
16.6%
|
✔
|
✔
|
✔
|
✔
|
(Watson, Ferguson et al. 2015)
|
✔
|
✔
|
94.3%
|
✔
|
✔
|
✔
|
✔
|
(Young, Wagner et al. 1996)
|
✔
|
✔
|
96.0%
|
✔
|
NR
|
✔
|
✔
|
Table 6. Type of triage system used in articles included for review
#
|
Triage System
|
Citations
|
12
|
Canadian Triage and Acuity Scale (CTAS)
|
17-19,29,31,32,42,49,57,63,97,98
|
5
|
Manchester Triage System (MTS)
|
25,55,66,91,95
|
5
|
Emergency Severity Index (ESI)
|
33,39,45,59,89
|
4
|
Australasian Triage Scale (ATS)
|
37,48,50,51
|
2
|
Australian Institute of Health and Welfare (AIHW)
|
28,56
|
2
|
Swiss Emergency Triage Scale (SETS)
|
76,102
|
1
|
ELISA Scale
|
65
|
1
|
French Emergency Nurses Classification in Hospital Scale, Classification Infirmière des Malades aux Urgences (CIMU)
|
72
|
1
|
German Society of Traumatology guidelines
|
103
|
1
|
Hospital Authority of Hong Kong, Accident and emergency department triage guidelines
|
78
|
1
|
Hospital Urgencies Appropriateness Protocol (HUAP)
|
62
|
1
|
Japan Triage and Acuity Scale (JTAS)
|
73
|
1
|
Kentucky Emergency Nurses Association standard
|
99
|
1
|
South African Triage Score
|
74
|
1
|
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
|
46
|